Drug-eluting stents not cost-effective if used in all patients

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NEW YORK (Reuters Health), Nov 2 - In the long-term, drug-eluting stents (DES) are not a good value for the money if used in all patients with coronary artery disease, according to a report in the November 3rd issue of the Lancet.

The results suggest that DES are cost-effective when used in patients requiring small vessel or bypass graft stenting, but not when used in patients requiring stenting of large native vessels.

"Up to now, the discussion was always that DES are all good (initially) and later on that DES are all bad," senior author Dr. Matthias Pfisterer told Reuters Health. "We propose a more differentiating look at DES: there is a distinct group of high-risk patients where DES are beneficial -- and cost-effective or even cost-saving -- whereas there is another group where DES have only a small benefit, possibly a late 'harm' and are not cost-effective."

The new study involved an 18-month cost-effectiveness analysis of data from the Basel Stent KostenEffektivitats Trial (BASKET), which included 545 patients randomized to receive a DES and 281, a bare-metal stent.

The overall cost of DES per patient was higher than with bare metal stents: 11,808 versus 10,450 euros (p < 0.0001), Dr. Pfisterer and colleagues, from University Hospital in Basel, Switzerland, note. The incremental cost-effectiveness ratio (ICER) to prevent one major cardiac event was 64,732 euros and the cost per quality-adjusted life year (QALY) gained was 40,467 euros.

In low-risk patients (large native vessel stenting), the probability that a DES would achieve an ICER of 10,000 euros or less to prevent one major cardiac event was just 0.016. By contrast, the corresponding probability in high-risk patients (small vessel or bypass graft stenting) was 0.874.

The principal message, according to Dr. Pfisterer, is that if a clinician "cares about cost-effectiveness (which depends on the health and reimbursement system), he should use DES selectively in high-risk patients as defined in this study and use bare-metal stents in the remaining majority of patients."

By Anthony J. Brown, M.D.

Last Updated: 2007-11-01 18:30:10 -0400 (Reuters Health)

Lancet 2007;370:1552-1559.

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