Benefits of drug-eluting stents (DES) in percutaneous coronary intervention (PCI) are greatest in those at the highest risk of target-vessel revascularization (TVR). Drug-eluting stents cost more than bare-metal stents (BMS) and necessitate prolonged dual antiplatelet therapy (DAPT), which increases costs, bleeding risk, and risk of complications if DAPT is prematurely discontinued. Our objective was to assess whether DES are preferentially used in patients with higher predicted TVR risk and to estimate if lower use of DES in low-TVR-risk patients would be more cost-effective than the existing DES use pattern.
We analyzed more than 1.5 million PCI procedures in the National Cardiovascular Data Registry (NCDR) CathPCI registry from 2004 through 2010 and estimated 1-year TVR risk with BMS using a validated model. We examined the association between TVR risk and DES use and the cost-effectiveness of lower DES use in low-TVR-risk patients (50% less DES use among patients with <10% TVR risk) compared with existing DES use.
There was marked variation in physicians' use of DES (range 2%-100%). Use of DES was high across all predicted TVR risk categories (73.9% in TVR risk <10%; 78.0% in TVR risk 10%-20%; and 83.2% in TVR risk >20%), with a modest relationship between TVR risk and DES use (relative risk, 1.005 per 1% increase in TVR risk [95% CI, 1.005-1.006]). Reducing DES use by 50% in low-TVR-risk patients was projected to lower US health care costs by $205 million per year while increasing the overall TVR event rate by 0.5% (95% CI, 0.49%-0.51%) in absolute terms.
Use of DES in the United States varies widely among physicians, with only a modest correlation to patients' risk of restenosis. Less DES use among patients with low risk of restenosis has the potential for significant cost savings for the US health care system while minimally increasing restenosis events.
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Figure 1. Physician level variation in the use of drug-eluting stents (DES). The physicians include the individual physicians (n = 2715) in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, version 4 data, who performed more than 75 percutaneous coronary interventions (PCIs) annually. These physicians are ranked in ascending order of rate of DES use, such that those using the least DES are to the left and those using the highest DES are to the right.
Figure 2. Incremental cost-effectiveness (A) and cost-effectiveness acceptability curve (B) for drug-eluting stent (DES) use. Illustrated is the comparison between DES lower use strategy (base case) in patients at low risk of target-vessel revascularization (TVR) vs DES existing use strategy in the 1000 NCDR samples generated by sampling-based probabilistic sensitivity analysis. A, For incremental effectiveness (TVR events avoided), points to the left of 0 indicate decreased efficacy (more TVR events with lower DES use strategy vs existing DES use strategy). For incremental costs (measured in thousands of dollars) points below 0 indicate costs saved by a lower DES use strategy. The ellipse represents the 95% confidence ellipse and contains 95% of the simulations. B, The solid vertical line represents the $10 000/TVR avoided threshold. Cost-effective probability indicates the proportion of simulations that are cost-effective. The curve is the cumulative probability density function of the 1000 trial replicates; 98.3% of the 1000 trial replicates showed an incremental cost-effectiveness ratio for DES existing use vs lower use strategy that exceeded $10 000/TVR avoided.
Figure 3. Sensitivity of projected cost savings to assumed reductions in drug-eluting stent (DES) use in patients at low risk for target-vessel revascularization (TVR). The x-axis shows modeled rates of DES use in the low-TVR-risk group. The first bar (far left) represents 100% bare-metal stent (BMS) use in this predicted low-TVR-risk group, while the last bar (far right) represents existing use rate or 74% DES use in the low-TVR-risk group. The y-axis on the left shows the US annual costs saved per year in patients undergoing percutaneous coronary intervention (bars). The y-axis on the right shows the absolute increase in TVR event rate (black line).
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