What Are the Clinical and Economic Implications of Using DES in Practice?

A study published July 9 in the Archives of Internal Medicine found that reducing the use of drug-eluding stents (DES) among patients at low risk for restenosis has the potential to reduce health care costs with only a minimal increase in target vessel revascularization (TVR) events.

Although DES are effective in reducing restenosis, "several studies have demonstrated that the benefits of DES in reducing the need for TVR are largely confined to subsets of patients at high risk of restenosis with bare-metal stents (BMS)." The authors note, "whether DES are preferentially used among patients at higher risk of restenosis in current clinical practice is unknown."

The authors looked at more than 1.5 million percutaneous coronary intervention (PCI) procedures in the National Cardiovascular Data Registry (NCDR) CathPCI Registry from 2004 to 2010. They aimed "to determine current patterns of DES use as a function of TVR risk and the potential clinical and economic implications of more tailored DES use."

Additional Resources
  • Full Study
  • Horizons-AMI Trial Summary 
  • Journal Scan: Effectiveness and Safety of Drug-Eluting Stents in Ontario 
  • CardioSmart for Your Patients: Caring for Your Heart After a Stent
  • Results showed that "in current U.S. practice, DES use is prevalent, even among patients at lower risk of developing restenosis." Use was "high across all predicted TVR risk categories (73.9 percent in TVR risk <10 percent; 78.0 percent in TVR risk 10-20 percent; and 83.2 percent in TVR risk >20 percent), with a modest relationship between TVR risk and DES use (relative risk, 1.005 per 1 percent increase in TVR risk [95 percent CI, 1.005-1.006])." The authors also found that, "reducing DES use by 50 percent in low-TVR-risk patients was projected to lower U.S. health care costs by $205 million per year while increasing the overall TVR event rate by 0.5 percent."

    Based on these findings, "there appears to be an important opportunity to tailor DES use to those with the greatest potential to benefit and reduce its use in those with favorable outcomes after BMS alone," note the authors.

    They add that their study "illustrates the potential for cost savings, without a significant increase in patient morbidity, that could be achieved with an evidence-based approach to current stent selection, and to encourage shared decision making with patients."

    In a commentary, Peter Groeneveld, MD, MS, from the University of Pennsylvania School of Medicine, Philadelphia, Pa. notes, "the U.S. 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 cost – 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."

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