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Use of Drug-Eluting Stents as a Function of Predicted Benefit: Clinical and Economic Implications of Current Practice
Study Questions:
What are the estimated clinical and economic consequences of lower drug-eluting stent (DES) use among patients with low target vessel revascularization (TVR) risk?
Methods:
The investigators analyzed more than 1.5 million percutaneous coronary intervention (PCI) procedures in the National Cardiovascular Data Registry (NCDR) CathPCI registry from 2004 through 2010, and estimated 1-year TVR risk with bare-metal stents (BMS) using a validated model. They 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. The authors compared the rates of DES use in low-, medium-, and high-TVR-risk groups, and estimated the unadjusted association of TVR risk with DES use by means of modified Poisson regression.
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% confidence interval [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:
The authors concluded that less DES use among patients with a low risk of restenosis has the potential for significant cost savings for the US health care system while minimally increasing restenosis events.
Perspective:
The present study demonstrates that in current US practice, DES use is prevalent, even among patients at low risk of developing restenosis. There was also significant variation in the rate of DES use by individual physicians. Furthermore, a reduction in DES use among patients at low risk for restenosis was projected to be associated with substantial costs savings, with only a small increase in TVR events. More appropriate evidence-based use of DES offers an important opportunity to reduce health care expenditures, while preserving the vast majority of their clinical benefit and value.
Keywords: Coronary Restenosis, Drug-Eluting Stents, Cost Savings, Percutaneous Coronary Intervention
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