Are Drug-Eluting Stents Cost-Effective?

Abstract

Since their commercial introduction in 2003, drugeluting stents (DES) have rapidly altered the management of coronary artery disease. Before their development, the percutaneous management of coronary artery disease was performed predominantly by implantation of bare metal stents (BMS) made of either surgical stainless steel or metal alloys. Although such stents represented a considerable advance over balloon angioplasty alone, they remained limited by restenosis resulting from neointimal proliferation. As a result, Ϸ15% to 20% of patients treated with BMS required Ն1 repeat revascularization procedure within the 6 to 12 months after stent implantation. 1 Despite numerous attempts at systemic pharmacotherapy, device modification, and even use of ionizing radiation, the rate of restenosis after BMS implantation remained largely unaffected. Response by Eisenberg p 1744Over the past 5 years, effective DES have become the first device to substantially reduce the incidence of restenosis after stent implantation. By delivering high concentrations of either antiproliferative or immunomodulatory compounds directly to the site of arterial injury and by controlling this delivery through polymer-based drug release, both sirolimus-and paclitaxel-eluting stents have safely and effectively inhibited the proliferative process that results in in-stent restenosis. In pivotal clinical trials, both sirolimus-and paclitaxel-eluting stents have reduced rates of angiographic restenosis by 70% to 90% compared with conventional BMS designs, with parallel reductions in the need for clinically driven target vessel revascularization (TVR). 2-4 As a result, in April 2003, DES were approved for use in clinical practice in the United States. Within 9 months of their introduction, DES made up 35% of all stent implantations in the United States, 5 and their use has increased rapidly since that time. At our own institution, DES comprised Ͼ85% of all stents implanted during the past year, and national estimates are that Ͼ90% of all percutaneous coronary intervention (PCI) procedures currently performed in the United States involve Ն1 DES.Given current procedural volumes (Ͼ1 million PCI procedures were performed in the United States in 2004) 6 and costs (DES are generally 3 to 4 times more expensive than BMS), the rapid growth of this technology has raised important concerns about cost from both a hospital and a societal perspective. 7,8 Because annual increases in US healthcare expenditures consistently outpace inflation, 9 there is increasing interest in formally evaluating the economic impact of new technologies both before and immediately after their introduction. The aim of the present report is to summarize the economic consequences of current DES use and to explore the possible future impact of DES on US healthcare expenses.

Custo-efetividade dos stents recobertos por rapamicina em procedimentos percutâneos coronarianos no Brasil

“…It was estimated that, if drug-eluting stent were used, there would be an increment of R$9,524 per patient, with the cost per event avoided being over R$190,000. These figures were far higher than those described in other studies, probably because the target-vessel revascularization rate in the cohort with large vessels studied was as low as 5.8% 33 .…”

Temporal Changes in Coronary Revascularization Procedures, Outcomes, and Costs in the Bare-Metal Stent and Drug-Eluting Stent Eras

“…6,7 In controlled trials among patients with complex lesions and high rates of BMS restenosis, formal economic evaluations have suggested that DES may be reasonably cost-effective. 8,9 On the other hand, studies involving broader populations have suggested that widespread adoption of DES may be a relatively inefficient use of scarce resources, particularly in healthcare systems outside the United States.…”

Drug-eluting stents: A study of international practice

“…Despite their established effectiveness in randomized controlled trials, the clinical and cost effectiveness of unrestricted DES use in routine practice has since been debated. [5][6][7][8] Given the financial consequences of widespread use of these more expensive stents, some health care systems introduced guidelines or encouraged restricted indications for DES use; such approaches have varied. [9][10][11][12] Against this background, abstracts presented at the World Congress of Cardiology (WCC) in September 2006 brought into question the safety of DES and, in particular, the complication of late stent thrombosis.…”