title: Clinical and economic outcomes of liberal versus selective drug-eluting stent use: insights from temporal analysis of the multicenter Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry.
abstract: BACKGROUND
  Although the benefits of drug-eluting stents (DES) for reducing restenosis after percutaneous coronary intervention are well established, the impact of alternative rates of DES use on population-level outcomes is unknown.
  
  
  RESULTS
  We used data from the Evaluation of Drug Eluting Stents and Ischemic Events (EVENT) registry to examine the clinical impact and cost-effectiveness of varying DES use rates in routine care. Between 2004 and 2007, 10,144 patients undergoing percutaneous coronary intervention were enrolled in the EVENT registry at 55 US centers. Clinical outcomes and cardiovascular-specific costs were assessed prospectively over 1 year of follow-up. Use of DES decreased from 92 in 2004 to 2006 (liberal use era; n=7587) to 68 in 2007 (selective use era; n=2557; P<0.001). One-year rates of death or myocardial infarction were similar in both eras. Over this time period, the incidence of target lesion revascularization increased from 4.1 to 5.1, an absolute increase of 1.0 (95 confidence interval, 0.1 to 1.9; P=0.03), whereas total cardiovascular costs per patient decreased by $401 (95 confidence interval, 131 to 671; P=0.004). The risk-adjusted incremental cost-effectiveness ratio for the liberal versus selective DES era was $16,000 per target lesion revascularization event avoided, $27,000 per repeat revascularization avoided, and $433 000 per quality-adjusted life-year gained.
  
  
  CONCLUSIONS
  In this prospective registry, a temporal reduction in DES use was associated with a small increase in target lesion revascularization and a modest reduction in total cardiovascular costs. These findings suggest that although clinical outcomes are marginally better with unrestricted DES use, this approach represents a relatively inefficient use of healthcare resources relative to several common benchmarks for cost-effective care.
authors.affiliation: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, School of Medicine, 4401 Wornall Rd, Kansas City, MO 64111, USA. dcohen@saint-lukes.org
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Venkitachalam
authors.forename: Yang
authors.initials: Y
authors.lastname: Lei
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Stolker
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Mahoney
authors.forename: Amit P
authors.initials: AP
authors.lastname: Amin
authors.forename: Jason B
authors.initials: JB
authors.lastname: Lindsey
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Pencina
authors.forename: John J
authors.initials: JJ
authors.lastname: Lopez
authors.forename: Neal S
authors.initials: NS
authors.lastname: Kleiman
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000191:economics; D003327:Coronary Disease / Q000191:economics / Q000601:surgery; D023903:Coronary Restenosis / Q000191:economics; D003362:Cost-Benefit Analysis; D054855:Drug-Eluting Stents / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000191:economics / Q000453:epidemiology; D011446:Prospective Studies; D019057:Quality-Adjusted Life Years; D012042:Registries / Q000706:statistics & numerical data*; D016896:Treatment Outcome