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Less DES use among low-risk patients can cut health care costs
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Halving the use of drug-eluting stents in patients at low risk for target vessel revascularization may decrease health care costs by more than $200 million, according to new data published in the Archives of Internal Medicine.
Amit P. Amin, MD, MSc, of Barnes Jewish Hospital, Washington University School of Medicine, St. Louis, Mo., and colleagues evaluated more than 1.5 million percutaneous coronary intervention performed from 2004 to 2010 included in the National Cardiovascular Data Registry CathPCI registry. They employed a validated prediction model incorporating sociodemographic, clinical and angiographic variables to estimate risk for target vessel revascularization assuming treatment with bare metal stents (BMS). They then evaluated the relationship between target vessel revascularization risk and DES use and analyzed the cost-effectiveness of reduced DES use in patients with a less than 10% risk for target vessel revascularization.
Rising popularity, rising costs
Results indicated wide variation in DES use, ranging from 2% to 10%, among the 2,715 physicians performing 415,115 PCI procedures between 2009 and 2010. DES use remained prevalent across all target vessel revascularization risk categories: 73.9% among low-risk, 78% among moderate-risk and 78% among high-risk patients.
Researchers found a modest 0.53% relative increase in the rate of DES use with each 1% increase in predicted risk for target vessel revascularization with BMS (RR=1.005 per 1% increase in risk; 95% CI, 1.005-1.006).
According to the researchers’ projections, a 50% decrease in DES use among low-risk patients could result in net savings of $205 million, or $34,109 per 100 PCIs performed vs. current practice. These savings remained steady after accounting for a modest 0.5% absolute increase in repeated procedures due to target vessel revascularization.
“Given the marked variation in physicians’ DES use, a strategy of lower DES use among patients at low risk of [target vessel revascularization] could present an important opportunity to reduce health care expenditures while preserving the vast majority of their clinical benefit,” the researchers wrote.
A better system
In an invited commentary, Peter W. Groeneveld, MD, MS, of the University of Pennsylvania in Philadelphia, wrote, “New medical technologies are the primary drivers of rising health care costs, but the US health care system has generally performed poorly in incorporating new drugs, devices, imaging techniques and invasive procedures in a manner that maximizes the value — defined as health benefits relative to costs — delivered to patients while simultaneously restraining the use of such technologies in settings where they predictably provide little or no value.”
Groeneveld said a call for change is needed.
“The use pattern of DES during the past 9 years illustrates how far away the system is from consistently embracing value-based medical decision making, and it also enumerates the many barriers and inertial practices in US health care that must be surmounted to reach economic sustainability.”
For more information:
Amin AP. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.3093.
Groeneveld PW. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.2724.
Disclosure: See the study for a full list of the researchers’ disclosures. Dr. Groeneveld reports no relevant financial disclosures.