How Drug-Eluting Stents Illustrate Our Health System's Flawed Relationship With Technology Comment on “Use of Drug-Eluting Stents as a Function of Predicted Benefit” Value Lost With Drug-Eluting Stents

Groeneveld PW. — Mon, 13 Aug 2012 00:00:00 GMT

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. This tendency was clearly evident in the analysis by Amin et al of nationwide catheterization laboratory registry data. This study demonstrated the consistently high likelihood that US percutaneous coronary intervention (PCI) patients in 2004 through 2010 received a drug-eluting stent (DES), regardless of the presence of clinical predictors that suggested a low pretreatment risk of subsequent target-vessel revascularization (TVR), and TVR risk reduction is the only evidence-based benefit delivered by DES. In fact, 74% of such low-TVR-risk patients received a DES rather than a less costly bare metal stent (BMS)—arguably many of these were missed opportunities to maximize health care value. The authors further postulate that eliminating DES use among low-TVR-risk patients would save $400 million annually, at a cost of fewer than 1000 additional TVR cases per year. As TVR typically has only modest impact on patients' quality of life and negligible impact on lifespan, it is reasonable to conclude that such an economic tradeoff should be a societal “no brainer.”

Use of Drug-Eluting Stents as a Function of Predicted Benefit Clinical and Economic Implications of Current Practice Better Targeting Use of Drug Eluting Stents

Amin AP, Spertus JA, Cohen DJ, et al. — Mon, 13 Aug 2012 00:00:00 GMT

Background

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.

Methods

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.

Results

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.

Conclusions

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.

JAMA Internal Medicine: Percutaneous Coronary Intervention Topic Collection

How Drug-Eluting Stents Illustrate Our Health System's Flawed Relationship With Technology Comment on “Use of Drug-Eluting Stents as a Function of Predicted Benefit” Value Lost With Drug-Eluting Stents

Use of Drug-Eluting Stents as a Function of Predicted Benefit Clinical and Economic Implications of Current Practice Better Targeting Use of Drug Eluting Stents