Use of drug-eluting stents as a function of predicted benefit: clinical and economic implications of current practice.
BACKGROUND
Benefits of drug-eluting stents (DES) in percutaneous coronary intervention (PCI) are greatest in those at the highest risk of target-vessel revascularization (TVR). Drug-eluting stents cost more than bare-metal stents (BMS) and necessitate prolonged dual antiplatelet therapy (DAPT), which increases costs, bleeding risk, and risk of complications if DAPT is prematurely discontinued. Our objective was to assess whether DES are preferentially used in patients with higher predicted TVR risk and to estimate if lower use of DES in low-TVR-risk patients would be more cost-effective than the existing DES use pattern.


METHODS
We analyzed more than 1.5 million PCI procedures in the National Cardiovascular Data Registry (NCDR) CathPCI registry from 2004 through 2010 and estimated 1-year TVR risk with BMS using a validated model. We examined the association between TVR risk and DES use and the cost-effectiveness of lower DES use in low-TVR-risk patients (50% less DES use among patients with <10% TVR risk) compared with existing DES use.


RESULTS
There was marked variation in physicians' use of DES (range 2%-100%). Use of DES was high across all predicted TVR risk categories (73.9% in TVR risk <10%; 78.0% in TVR risk 10%-20%; and 83.2% in TVR risk >20%), with a modest relationship between TVR risk and DES use (relative risk, 1.005 per 1% increase in TVR risk [95% CI, 1.005-1.006]). Reducing DES use by 50% in low-TVR-risk patients was projected to lower US health care costs by $205 million per year while increasing the overall TVR event rate by 0.5% (95% CI, 0.49%-0.51%) in absolute terms.


CONCLUSIONS
Use of DES in the United States varies widely among physicians, with only a modest correlation to patients' risk of restenosis. Less DES use among patients with low risk of restenosis has the potential for significant cost savings for the US health care system while minimally increasing restenosis events.
Cardiovascular Division, Department of Medicine, Barnes Jewish Hospital, Washington University School of Medicine, St Louis, Missouri, USA.
Amit P
AP
Amin
John A
JA
Spertus
David J
DJ
Cohen
Adnan
A
Chhatriwalla
Kevin F
KF
Kennedy
Katherine
K
Vilain
Adam C
AC
Salisbury
Lakshmi
L
Venkitachalam
Sue Min
SM
Lai
Laura
L
Mauri
Sharon-Lise T
SL
Normand
John S
JS
Rumsfeld
John C
JC
Messenger
Robert W
RW
Yeh
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D057186:Comparative Effectiveness Research; D023903:Coronary Restenosis / Q000209:etiology / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D054855:Drug-Eluting Stents / Q000009:adverse effects / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D010043:Outcome and Process Assessment, Health Care; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D010818:Practice Patterns, Physicians'; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors
D010975:Platelet Aggregation Inhibitors