Circ: Selective stenting saves U.S. $400M annually
“Since their introduction into U.S. clinical practice in 2003, DES have dramatically altered the practice of interventional cardiology,” Lakshmi Venkitachalam, PhD, of Saint Luke’s Mid America Heart Institute in Kansas City, Mo., and colleagues wrote. “Although the benefits of DES for reducing restenosis after PCI are well established, the impact of alternative rates of DES use on population-level outcomes is unknown.”
In 2007, the FDA released an advisory statement cautioning against DES use in patients with “unapproved or untested indications.” After these concerns, DES stent use became more selective at centers and changed U.S. practice patterns.
To better understand the value and costs of DES use in the U.S., Venkitachalam et al used data from the EVENT (Evaluation of Drug Eluting Stents and Ischemic Events) registry to examine the cost-effectiveness and impact of the utilization of DES in practice.
The EVENT registry outlined PCI outcomes in the U.S. between 2004 and 2007. The registry enrolled 10,144 patients. In the current analysis, Venkitachalam and colleagues found that the percentage of patients receiving at least one DES decreased from 92 percent between 2004 and 2006, to 68 percent in 2007. On average, patients treated in 2007 received fewer stents and had a shorter length of stay than those treated between 2004 and 2006.
The researchers found that DES was more likely to be used among younger patients and those who were undergoing PCI for stable coronary artery disease, left main or left anterior descending artery lesions, bifurcations, in-stent restenosis, longer lesions and smaller vessels.
The authors reported that initial hospital costs were $659 per patient higher between 2004 and 2006 compared to 2007. This was “driven largely by the more frequent use of DES and greater numbers of stents implanted per patient during the earlier time period," they noted. In fact, total one-year cardiovascular costs per patient were $401 higher between 2004 and 2006 compared to 2007.
Additionally, the researchers noted that the mean differences in total vessel revascularization (TVR) and target lesion revascularization (TLR) procedures increased to 1.9 additional TLR events per 100 patients treated and 1.6 more TVR events per 100 patients treated in 2007 versus 2004 to 2006.
After a risk-adjustment, the incremental cost-effectiveness ratio for the liberal versus selective DES use era was $16,000 per TLR event avoided. The probability that the incremental cost-effectiveness ratio was less than $10,000 per TLR even avoided was 30 percent.
“The bottom-line was that using drug-eluting stents in a relatively unselected way was only resulting in marginal improvement compared to more selective use,” said the study's senior author David J. Cohen, MD, director of cardiovascular research at Saint Luke’s. In the earlier years of broader use, “we were putting a lot more DES in and we benefited very few additional patients,” he said.
Between 2004 to 2006, and 2007, there was an almost 25 percent reduction in DES among patients undergoing PCI. While the researchers did find there to be a small increase in stent restenosis, there were no differences in terms of death or MI.
“In parallel with these changes in practice and outcomes, the estimated cost of cardiovascular care (including dual antiplatelet therapy and repeat revascularization procedures) decreased by an estimated $400 per patient between the liberal and selective DES eras,” the authors wrote.
“These findings thus suggest that in an era of constrained resources, a more selective approach to DES use would be preferred, at least on economic grounds,” Venkitachalam et al wrote. “With nearly one million PCI procedures annually in the U.S., adoption of the more selective DES strategy would be expected to result in almost $400 million per year in annual cost savings to the U.S. healthcare system.”
Despite the fact that the researchers found that more selective use of DES had an economic benefit, it was difficult to draw conclusions about the optimal patient population for DES or bare-metal stent (BMS) use. However, the researchers said that interventional cardiologists integrated clinical and angiographic factors to select patients for DES who had a higher risk of restenosis with BMS.
“These findings suggest that although clinical outcomes may be marginally better, an overall strategy of unrestricted use of DES may not represent an efficient use of scarce healthcare resources,” the authors concluded. “There are ways that we can enhance this treatment pattern through healthcare policies, professional guidelines or appropriate use criteria.”