Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost-utility study

Abstract

Objective: To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. Design: Cost-utility analysis of audit based patient subgroups by means of a simple economic model. Setting: Tertiary care. Participants: 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. Main outcome measures: Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. Results: Four factors were identified for patients undergoing elective surgery (n = 1951) and two for nonelective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the nonelective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be £112 (US$212, J162) (sirolimus stents) or £89 (US$167, J130) (paclitaxel stents). Conclusions: At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

Drug-eluting stents: a systematic review and economic evaluation

“…A total of 10 full economic evaluation studies ( [120][121][122][123][124][125] and four additional papers by handsearching. 82,[126][127][128] One of these was in Italian, 126 and hence could only be partially reviewed.…”

“…Furthermore, the Kaiser study included a third-generation BMS comparator (Vision). Only one of the studies was set in the UK 120 and the remaining nine were set in the USA, Canada or the rest of Europe. All of the studies were of 1 year duration, except Greenberg, which was over 2 years, Kaiser, which was over 6 months, and Shrive, which was set over a patient's lifetime.…”

“…Table 17 provides a summary of the key parameters in the models and their comparison with our previous publication. 120 The main areas of discrepancy were the number of stents used during repeat revascularisation procedures, costs of DES and BMS and waiting time for subsequent PTCA or CABG. Medtronic used 1.87 stents per repeat procedure but only 1.12 for the index procedures.…”

“…Utility measures were taken from Bagust and colleagues, 120 and for the secondary analysis from Oostenbrink and colleagues. 134 Waiting times for PTCA and CABG were set at 15 weeks, as estimated by Bagust and colleagues.…”

“…134 Waiting times for PTCA and CABG were set at 15 weeks, as estimated by Bagust and colleagues. 120 Cost data were taken from Bagust and colleagues, 120 NHS APC spell, UK NHS reference costs and Medtronic sources. Discounting was applied to the 5-year scenario at a rate of 3.5% for costs and 3.5% for effectiveness, in line with current NICE guidelines, but differing from the standard applied for this assessment.…”