Changing treatment patterns for coronary artery revascularization in Canada: the projected impact of drug eluting stents

Background

To evaluate current treatment patterns for coronary artery revascularization in Canada and explore the potential impact of drug eluting stents (DES) on these treatment patterns.

Methods

Eleven cardiologists at multiple Canadian academic centers completed a questionnaire on coronary artery revascularization rates and treatment patterns.

Results

Participating physicians indicated slightly higher rates of PTCA, CABG, and stent implantation than reported in CCN publications. Participants estimated that 24% of all patients currently receiving bare metal stents (BMS) would receive DES in the first year following DES approval in Canada, although there was a large range of estimates around this value (5% to 65%). By the fifth year following DES approval, it was estimated that 85% of BMS patients would instead receive DES. Among diabetic patients, estimates ranged from 43% in the first year following approval to 91% in the fifth year. For all patients currently receiving CABG, mean use of DES instead was estimated at 12% in the first year to 42% at five years; rates among diabetic patients currently undergoing CABG were 17% in the first year to 49% in the fifth year.

Conclusions

These results suggest a continued increase in revascularization procedures in Canada. Based on the panel's responses, it is likely that a trend away from CABG towards PTCA will continue in Canada, and will be augmented by the availability of DES as a treatment option. The availability of DES as a treatment option in Canada may change the threshold at which revascularization procedures are considered.

Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy

Object. Definitive data characterizing the safety and efficacy of carotid angioplasty with stent placement (CAS) for symptomatic, occlusive carotid artery (CA) disease require further refinements and standardization of techniques as well as large prospective studies on a par with the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Despite the absence of such data, many surgeons have performed angioplasty and stent placement in patients with clinical or anatomical features known to add significant perioperative risk and capable of disqualifying the patients from participation in NASCET. There exists no cost analysis comparing high-risk endarterectomy with percutaneous angioplasty and stent insertion.

Methods. Forty-five patients (29 men and 16 women) with high-risk, symptomatic CA stenosis have been treated with CAS at the authors' institution since 1996. Indications for this procedure included symptomatic recurrent stenosis following CA endarterectomy (CEA), active coronary disease, high CA bifurcation, and severe medical comorbidities. A long-standing CEA computer database was screened for control patients with similar risk factors; 391 patients (276 men and 115 women) were identified. Actual cost data, duration of hospital stay, and relevant clinical data from the time of treatment until hospital discharge were collected in each patient. The median total cost of CAS was $10,628, whereas that for CEA was $10,148 (p = 0.495).

Conclusions. In patients with high-risk, NASCET-ineligible CA stenosis there was no overall statistically significant cost difference between CEA and CAS. Given that there may not be a cost advantage for either procedure, procedural risk, efficacy, and durability should be key factors in determining the optimal treatment strategy.

What reimbursement for coronary revascularization with drug-eluting stents?

We investigated the clinical and economic impact of sirolimus-eluting coronary stents (SES) at a nationwide level as to advice about the feasible reimbursement policy for the Italian Health Care System (SSN). A decision model compared bare metal stents (BMS) and SES in terms of costs and repeat coronary revascularizations incurred in 12 months following the first revascularization. The model was compiled for eight subgroups of patients. Rates of events were derived from randomized trials and an 1,809-patient survey. National charges were used to evaluate resources consumption. Compared with BMS, the number of averted revascularizations with SES is 0.16 per patient. SES also save Euro 1,371 per patient. Total savings to SSN are proportional to the rate of SES adoption by Italian hospitals: assuming a complete replacement of BMS with SES, the model estimates that 7,095 revascularizations would be averted and more than Euro 60 million saved by the SSN in 1 year. To stimulate SES adoption a SES-specific DRG might by introduced with a reimbursement value 23% higher than the current charge. SES is thus a cost-saving strategy in the perspective of the SSN that could therefore support the introduction of the new technology by reimbursing about 80% of its current incremental acquisition cost.

Natural course of inoperable esophageal cancer treated with metallic expandable stents: quality of life and cost-effectiveness analysis

BACKGROUND AND AIM

The aim of this study was to evaluate the efficacy and safety of endoscopic therapy with self-expanding metallic endoprostheses in the management of malignant esophageal obstruction or stenosis and the cost-effectiveness of the method in patients suffering from primary esophageal carcinoma. All patients with inoperable esophageal cancers treated with either laser palliation or endoprosthesis insertion were studied retrospectively.

METHOD

Between May 1997 and December 2002 obstruction of the esophagus was diagnosed in 78 patients (52 male, 26 female, age range 53-102 years, mean 72.3 years). The etiology of obstruction was squamous cell carcinoma (n = 42) and adenocarcinoma of the esophagus (n = 36). The site of obstruction was in the upper (n = 1), in the middle (n = 38) and in the lower esophagus (n = 39). In 16 cases the gastroesophageal junction was also involved. Four patients had broncho-esophageal fistulas. In all cases the tumor was considered non-resectable. A total of 89 Ultraflex metal stents were introduced endoscopically. In 46 patients dilation with Savary dilators prior to stent placement was required.

RESULTS

Stents were placed successfully in all patients. After 48 h, all patients were able to tolerate solid or semisolid food. During the follow-up period eight patients developed dysphagia due to food impaction (treated successfully endoscopically). Eleven patients presented with recurrent dysphagia 4-16 weeks after stenting due to tumor overgrowth and were treated with placement of a second stent. The median survival time was 18 weeks. There was no survival difference between squamous cell and esophageal adenocarcinoma. A cost-effective analysis was performed, comparing esophageal stenting with laser therapy. The mean survival and the cost were similar. A small difference of 156 Euro was noted (3.103 Euro and 2.947 Euro for each group of patients, respectively). A significant improvement in quality of life was noted in patients that underwent stenting (96% and 75%vs 71% and 57% for the first 2 months).

CONCLUSION

Placement of self-expanding metal stents is a safe and cost effective treatment modality that improve the quality of life, as compared with other palliative techniques, for patients with inoperable malignant esophageal obstructions. In cases of expansion of the mass a second stent can be used; however, the overall survival of these patients, is poor.

Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

BACKGROUND

Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction.

METHODS

Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures.

RESULTS

Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941).

CONCLUSIONS

Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

Drug-coated Stents

Since its introduction in 1977, the success of percutaneous interventional cardiology has been limited by the occurrence of restenosis. Drug-eluting stents, particularly sirolimus- and paclitaxel-coated stents, have been shown in randomized controlled trials to dramatically reduce restenosis in single, de novo, native coronary arteries. Over the last 2 years, investigators have reported that these stents can also reduce restenosis in more complex patient situations such as in diabetics, during acute coronary syndromes, in long atherosclerotic lesions and small arteries, and even after in-stent restenosis. These outcomes increase the clinical value of this technology to "real world" practice. This article reviews the current state of our knowledge regarding drug-eluting stents and identifies areas for further research.

In-hospital Costs of Self-Expanding Nitinol Stent Implantation versus Balloon Angioplasty in the Femoropopliteal Artery (The VascuCoil Trial)

PURPOSE

Although several prospective studies have examined the safety and efficacy of stent placement for femoropopliteal arterial disease, the current cost of these procedures is unknown. To estimate and compare hospital costs associated with conventional balloon angioplasty (percutaneous transluminal angioplasty [PTA]) and stent placement for patients with symptomatic peripheral arterial disease, the authors performed a prospective economic evaluation in conjunction with the Intracoil Femoropopliteal Stent Trial (VascuCoil).

MATERIALS AND METHODS

Between May 1997 and December 1999, 266 patients with stenotic or occluded superficial femoral or popliteal arteries were prospectively randomized to treatment with the IntraCoil stent or PTA. Detailed resource use and cost data for each patient's initial revascularization procedure and ensuing hospitalization were collected and analyzed on an intention-to-treat basis.

RESULTS

Compared with conventional balloon angioplasty, stent placement did not improve clinical outcomes but increased procedure duration, equipment costs, and physician services. As a result, initial hospital costs were approximately 3,500 dollars higher for patients randomized to the IntraCoil stent, compared with PTA (8,435 dollars vs 4,980 dollars; P < .001).

CONCLUSIONS

As performed in the VascuCoil trial, primary stent placement for femoropopliteal disease did not improve clinical outcomes but increased initial treatment costs by more than 3,000 dollars. Because there were no substantial differences in subsequent clinical outcomes between the two treatments, it is unlikely that these increased initial costs would be offset by savings in follow-up costs. These findings suggest that a strategy of routine stent implantation for patients undergoing femoropopliteal PTA is not optimal on economic grounds and that PTA with provisional stent implantation is preferred.

Review of recent US cost estimates of revascularization

OBJECTIVE

To review recent US cost estimates of revascularization and discuss their implications for third-party payers.

STUDY DESIGN AND METHODS

A literature review was performed using MEDLINE. The review was limited to English-language articles published between January 2000 and September 2003. The most recently published articles that included US-derived clinical outcomes and costs of revascularization were selected for review. Cost estimates were abstracted and updated to 2003.

RESULTS

Coronary revascularization procedures, including percutaneous coronary interventions (PCIs) and coronary artery bypass graft (CABG), are commonly performed in the United States. These procedures are costly. Costs for PCI in single-vessel disease are lower than costs for PCI in multivessel disease. Although initial estimated costs are lower for multivessel PCI (with or without stenting) than CABG, longer-term costs and lifetime costs are similar. Drug-eluting stents have the potential to alter treatment and economics dramatically, although it is too early to draw definitive conclusions about their costs. It is imperative that cost comparisons be placed in the appropriate context.

CONCLUSION

Revascularization procedures are costly, and short-term cost differences in procedures may not exist when considered long term. Importantly, recent cost data may be conservative given the rapid innovation in revascularization procedures and technology and the lag in publication of cost data reflecting these advances.

Coronary artery stents: a rapid systematic review and economic evaluation

OBJECTIVES

To assess the effectiveness and cost-effectiveness of the use of coronary artery stents in patients with coronary heart disease (CHD).

DATA SOURCES

Electronic databases.

REVIEW METHODS

The review was conducted following accepted guidelines for conducting systematic reviews. Randomised controlled trials that include comparisons of percutaneous transluminal coronary angioplasty (PTCA) versus PTCA with stent, stent versus coronary artery bypass graft (CABG), and drug-eluting stents (DES) versus non-DES in patients with CAD in native or graft vessels and those with stable angina or acute coronary syndrome (ACS) and unstable angina were also included. Data on the following outcome measures were included in the review: combined event rate or event-free survival, death, acute myocardial infarction, target vessel revascularisation, repeat treatment (PTCA, stent or CABG) and binary restenosis. An economic model was developed based on extrapolation of trends in mortality and revascularisation from clinical trials data to a 5-year time horizon.

RESULTS

The inclusion criteria were fulfilled by 50 studies comparing the use of stents with PTCA, six comparing stents with CABG and 12 comparing DES eluting stents with non-DES. No studies were identified that compared DES with PTCA or DES with CABG. Existing quality of life data suggest that revascularisation procedures reduce the patient's quality of life for a short period only. Stents were found to be more effective than PTCA in preventing adverse events and revascularisations. In multiple-vessel disease there was no evidence of a difference in mortality (at 1 year) between patients treated surgically and those receiving a stent. Patients treated surgically required fewer revascularisations. There is no evidence of a difference in mortality between patients receiving DES and those treated with bare metal stents at 1 year. A reduction in event rate at 9 and 12 months was found in patients treated with DES. This event rate is primarily made up of increased revascularisation rates in patients treated with bare metal stents. Two-year outcome data from one study indicate that this benefit of DES continues over the longer term. The economic model proved sufficient to indicate long-term trends in cost-effectiveness. CABG was found initially to be more expensive than bare metal stenting in multivessel disease and may have higher immediate risks, but over time the cost differential is reduced and long-term outcomes favour CABG over stenting. A similar situation was found for DES versus CABG in multiple-vessel disease. However, DES may not generally be considered a cost-effective alternative to bare metal stenting in single-vessel disease by policy makers as substantially higher costs are involved with a very small outcome benefit.

CONCLUSIONS

DES might be considered cost-effective if the additional cost (compared with ordinary stents) was substantially reduced, the outcome benefits from the use of DES were much improved, and/or its use were targeted on the subgroups of patients with the highest risks of requiring reintervention. Long-term clinical studies are needed that focus on significant outcomes such as mortality. Further research should consider: the differences among plain stents; head-to-head comparisons within DES, CABG compared with DES; and the evaluation of newer non-DES against DES. Evaluation of the effects of revascularisation procedures and especially repeat revascularisation procedures on the patient's quality of life would also be useful, as would the development and testing of risk assessment tools to identify patients likely to need further revascularisations.

Feasibility and cost of treatment with drug eluting stents of surgical candidates with multi-vessel coronary disease*1

OBJECTIVE

To determine the feasibility and cost of treatment with drug eluting stents in patients with multi-vessel coronary disease referred currently for surgical revascularisation.

METHODS

Two experienced interventional cardiologists reviewed retrospectively the clinical records and pre-operative coronary angiograms of 209 patients who underwent their first coronary bypass operation for multi-vessel disease without other adjunctive surgical procedures at the Royal Brompton Hospital in 2002. They were classified according to the technical feasibility and completeness of percutaneous revascularisation. A cost decision-analysis model with a cost of drug eluting stents of euro 2,100 and simulated 1-year costs was constructed.

RESULTS

Mean age was 64.6+/-8.9 years with 54 diabetics (25.8%). Each patient received at least 1 arterial graft and a mean of 3.0+/-0.8 distal anastomoses. Mean post-operative stay was 8.9+/-7.2 days and total cost euro 19,821+/-1,964. Percutaneous revascularisation was judged to be feasible in 158 (76%) cases. The contraindications were at least 1 unfavourable total occlusion subtending viable myocardium in 48 patients (23%) and extreme tortuosity or calcification in 4 patients (2%). Percutaneous revascularisation of grafted major epicardial vessels was anticipated to be complete in 138 (66%) patients and partial but acceptable in 19 (9.1%) patients. Stenting of the left main, of a 'favourable' total occlusion, of bifurcations or in an ostial location would have been required in 32 (20.4%), 60 (38.2%), 77 (49.0%) and 74 (47.1%), respectively, of cases treated. 3.6+/-1.4 drug eluting stents of total length 72.6+/-37.3 mm were required to treat 3.3+/-1.2 lesions per patient at an estimated cost of euro 17,266+/-2,850. When one year repeat revascularisation was modelled at a rate of 15% in the stent group there was no significant cost saving from stenting.

CONCLUSIONS

Although percutaneous revascularisation is feasible in 76% of patients currently undergoing coronary artery bypass grafting for multi-vessel disease, such an approach will involve frequent treatment of complex lesions for which no long term results are available and is unlikely to provide appreciable economic savings.

Wann sind Drug-eluting Stents als wirksam zu bezeichnen?

The use of drugeluting stents (DES) has tackled the "Achilles' heel" of percutaneous coronary interventions (PCI) like no innovation before: the restenosis following initially successful PCI of de novo stenoses. Today, with DES, the pivotal clinical parameter TVF (target vessel failure) is in the upper single- digit range for "standard" lesions and 16% for long lesions. Numerous studies have assessed the effects of various antiproliferative and antiinflammatory substances, like Sirolimus, Tacrolimus, Everolimus, ABT-578, Biolimus, Paclitaxel, QP2 as well as of other drugs, like Dexamethasone, 17-beta-Estradiol, Batimastat, Actinomycin-D, Methotrexat, Angiopeptin, Tyrosinkinase inhibitors, Vincristin, Mitomycin, Cyclosporin, and also the C-myc antisense technology (Resten-NG, AVI-4126). At the time of this analysis, four DES are CE-certified and commercially available in Europe: The Cypher stent, releasing Sirolimus from a polymer (Cordis, J&J), the Taxus stent, releasing Paclitaxel from a polymer (Boston-Scientific), the V-Flex stent, releasing Paclitaxel without a polymer (Cook) and the Dexamet stent, releasing Dexamethasone from a PC coating (Abbott). Since more DES will be CE-certified soon, an increasing challenge vexes interventional cardiologists and health care providers: Which DES should be chosen for routine patient care?A prerequisite for assessing the efficacy of DES are randomized, controlled trials. Registries, even with strong monitoring, are limited by the known restrictions, comparing data to historical controls. At the time of this analysis, only three drugs had proven their efficacy in 13 randomized studies in 5669 patients: Paclitaxel, Sirolimus and Everolimus, with 3815 patients in Paclitaxel studies, 1748 patients in Sirolimus studies and 106 patients in Everolimus studies. For further analysis, it makes sense to divide the primary endpoints into non-clinical and clinical endpoints. Non-clinical primary endpoints are usually angiographic parameters, like the percentage of DS (diameter stenosis, ASPECT, ELUTES), the instent LLL (late lumen loss, RAVEL, FUTURE-II), the in-stent MLD (minimal lumen diameter, E-SIRIUS, C-SIRIUS) or, like in TAXUS-II, the IVUS-determined percentage of volume obstruction. Clinical primary endpoints were either MACE (major adverse cardiac events, TAXUS-I, FUTUREI), TVF (target vessel failure, DELIVER-I, SIRIUS) or TVR (target vessel revascularization, TAXUS-IV und TAXUS-VI). As ASPECT, ELUTES and DELIVER-I have shown, even a statistically significant effect on an angiographic primary endpoint does not necessarily translate into a significant clinical effect, which is completely absent in some such cases. Since it is not the goal of PCI to improve angiographic parameters but rather to improve patients' outcome, the choice of DES for routine treatment should be based on the results of randomized controlled studies with a clinical primary endpoint at an appropriate time interval. At the present time, these criteria have been met by only the Cypher and the Taxus stents.

Vergütung radiologischer Gefäßinterventionen im DRG-System: Was wird sich ändern?

PURPOSE

To evaluate reimbursement within the DRG-system ("diagnosis-related groups") compared with traditional reimbursement for interventional therapy of hospitalized patients.

MATERIALS AND METHODS

Reimbursement calculation was prospectively analyzed in two respects for 30 consecutive patients who underwent percutaneous transluminal angioplasty (PTA) of the lower extremity arteries: (1) based on the DRG-system; (2) based on the traditional system. Additional evaluation was performed for five further, typical vascular procedures on the basis of real documentation and calculation data (stenting of the carotid artery, fibrinolytic therapy of basilar artery occlusion, stenting of renal artery stenosis, angioplasty of hemodialysis-shunt stenosis and aspiration thrombectomy of an infrapopliteal arterial occlusion).

RESULTS

In our hospital, the introduction of the DRG system would reduce reimbursement by approximately 1100 euro per PTA patient. However, the other vascular radiological procedures can be expected to increase the payments by up to 4500 euro.

CONCLUSION

To minimize imminent reduction of reimbursement for patients with peripheral PTA, complete documentation and economical patient management is mandatory. Payment may increase significantly for patients with the other reported vascular interventional procedures.

Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation

Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group ( p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were $7215 for the stented group and $10,190 for the open surgery group ( p < 0.05). Palliation of the gastroduodenal obstruction in patients with malignant disease were at least as good, and the charges were lower for the endoscopic stenting procedure than for an open surgical bypass.

[Potential impact of drug-eluting stents in Sicily: results from a multicenter survey and cost-benefit analysis of drug-eluting stents versus bare metal stents]

BACKGROUND

The recent introduction of drug-eluting stents (DES) has shown, in randomized controlled trials, to reduce the incidence of restenosis as compared to bare metal stents (BMS). Since their cost is considerably higher than that of BMS, the study assessed the economic impact of the adoption of this new therapy in the Sicilian clinical practice.

METHODS

An economic evaluation was carried out by means of a linear decision model developed in Excel that simulated and compared costs and clinical pathway, within 1 year of the intervention, of hypothetical groups of patients with de novo lesions undergoing angioplasty with DES or BMS. Clinical data were obtained from the available literature and adapted to the Sicilian reality, using data from an original survey conducted in 7 local cath labs. The survey collected information on the anatomical case-mix of the population treated, the average number of stents used in the various procedures and the methods of treatment for in-stent restenosis.

RESULTS

Compared to BMS, DES allows to avoid, on average, 11.8 revascularizations out of 100 patients over a period of 1 year, but requires to bear an incremental net cost of Euro 931 for the annual treatment of each patient. The cost-benefit ratio is more favorable for those categories of patients/lesions in which the risk of in-stent restenosis is higher and, at the same time, the number of stents implanted per procedure is lower (single-vessel diabetics and small vessels).

CONCLUSIONS

The results of the study show how, within the scope of a policy that has tended more and more to rationalize the use of available health resources, the use of the expensive DES is not justified from an economic point of view in groups of patients and types of lesions in which a BMS is also associated with a lower likelihood of revascularization. Therefore, the study provides a starting point for consideration by hospital centers, suggesting the use of a mixture of DES for the treatment of lesions/patients at the highest risk of restenosis and BMS for the treatment of lesions/patients at lower risk of re-intervention.

Cost-effectiveness of sirolimus-eluting stents for treatment of complex coronary stenoses: results from the Sirolimus-Eluting Balloon Expandable Stent in the Treatment of Patients With De Novo Native Coronary Artery Lesions (SIRIUS) trial

BACKGROUND

Recently, sirolimus-eluting stents (SESs) have been shown to dramatically reduce the risk of angiographic and clinical restenosis compared with bare metal stent (BMS) implantation. However, the overall cost-effectiveness of this strategy is unknown.

METHODS AND RESULTS

Between February and August 2001, 1058 patients with complex coronary stenoses were enrolled in the SIRIUS trial and randomized to percutaneous coronary revascularization with either a SES or BMS. Clinical outcomes, resource use, and costs were assessed prospectively for all patients over a 1-year follow-up period. Initial hospital costs were increased by 2881 dollars per patient with SESs. Over the 1-year follow-up period, use of SESs led to substantial reductions in the need for repeat revascularization, including repeat percutaneous coronary intervention and bypass surgery. Although follow-up costs were reduced by 2571 dollars per patient with SESs, aggregate 1-year costs remained 309 dollars per patient higher. The incremental cost-effectiveness ratio for SES was 1650 dollars per repeat revascularization event avoided or 27,540 dollars per quality-adjusted year of life gained, values that compare reasonably with other accepted medical interventions. Under updated treatment assumptions regarding available stent lengths and duration of antiplatelet therapy, use of SESs was projected to reduce total 1-year costs compared with BMSs.

CONCLUSIONS

Although use of SESs was not cost-saving compared with BMS implantation, for patients undergoing percutaneous coronary intervention of complex coronary stenoses, their use appears to be reasonably cost-effective within the context of the US healthcare system.

Cost study of metal stent placement vs single-dose brachytherapy in the palliative treatment of oesophageal cancer

Self-expanding metal stent placement and single-dose brachytherapy are commonly used for the palliation of oesophageal obstruction due to inoperable oesophagogastric cancer. We randomised 209 patients to the placement of an Ultraflex stent (n=108) or single-dose brachytherapy (12 Gy, n=101). Cost comparisons included comprehensive data of hospital costs, diagnostic interventions and extramural care. We acquired detailed information on health care consumption from a case record form and from monthly home visits by a specialised nurse. The initial costs of stent placement were higher than the costs of brachytherapy (€1500 vs €570; P<0.001). Total medical costs were, however, similar (stent €11 195 vs brachytherapy €10 078, P>0.20). Total hospital stay during follow-up was 11.5 days after stent placement vs 12.4 days after brachytherapy, which was responsible for the high intramural costs in both treatment groups (stent €6512 vs brachytherapy €7982, P>0.20). Costs for medical procedures during follow-up were higher after stent placement (stent €249 vs brachytherapy €168, P=0.002), while the costs of extramural care were similar (€1278 vs €1046, P>0.20). In conclusion, there are only small differences between the total medical costs of both palliative treatment modalities, despite the fact that the initial costs of stent placement are much higher than those of brachytherapy. Therefore, cost considerations should not play an important role in decision making on the appropriate palliative treatment strategy for patients with malignant dysphagia.

A stent is not just a stent: Stent construction and design do matter in its clinical performance

The undisputed superiority of stents over conventional balloon angioplasty has resulted in a plethora of stents in clinical use. Recent data, however, have indicated not all stent models are the same. Nuances in stent design and construction have impacted significantly on the immediate and long-term clinical outcome. Among the stainless steel stents, those with multicellular or tubular designs have proven to be superior to coiled or hybrid stent models, and thin-strut stents perform better than thicker-strut stents. Coating stainless steel stents with gold, carbide, phosphorylcholine or heparin do not appear to confer any additional benefit, compared with bare metal stents. In contrast, randomised trials have demonstrated that drug-eluting stents coated with various anti-proliferative drugs, with or without a carrier polymer, afford unparalleled restenosis rates compared with non-drug-eluting stents. Drug-eluting stents, however, are expensive, and their long-term durability and safety remain undefined. Notwithstanding these unresolved issues, it is likely that the majority of percutaneous coronary interventions will involve the use of drug-eluting stents once a more attractive balance between their cost and clinical effects is reached.

One year comparison of costs of coronary surgery versus percutaneous coronary intervention in the stent or surgery trial

OBJECTIVES

To compare initial and one year costs of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in the stent or surgery trial.

DESIGN

Prospective, unblinded, randomised trial.

SETTING

Multicentre study.

PATIENTS

988 patients with multivessel disease.

INTERVENTIONS

CABG and stent assisted PCI.

MAIN OUTCOME MEASURES

Initial hospitalisation and one year follow up costs.

RESULTS

At one year mortality was 2.5% in the PCI arm and 0.8% in the CABG arm (p = 0.05). There was no difference in the composite of death or Q wave myocardial infarction (6.9% for PCI v 8.1% for CABG, p = 0.49). There were more repeat revascularisations with PCI (17.2% v 4.2% for CABG). There was no significant difference in utility between arms at six months or at one year. Quality adjusted life years were similar 0.6938 for PCI v 0.6954 for PCI, Delta = 0.00154, 95% confidence interval (CI) -0.0242 to 0.0273). Initial length of stay was longer with CABG (12.2 v 5.4 days with PCI, p < 0.0001) and initial hospitalisation costs were higher (7321 pounds sterling v 3884 pounds sterling for PCI, Delta = 3437 pounds sterling, 95% CI 3040 pounds sterling to 3848 pounds sterling). At one year the cost difference narrowed but costs remained higher for CABG (8905 pounds sterling v 6296 pounds sterling for PCI, Delta = 2609 pounds sterling, 95% CI 1769 pounds sterling to 3314 pounds sterling).

CONCLUSIONS

Over one year, CABG was more expensive and offered greater survival than PCI but little added benefit in terms of quality adjusted life years. The additional cost of CABG can be justified only if it offers continuing benefit at no further increase in cost relative to PCI over several years.

[Antiproliferative drug-eluting stents: systematic review of the benefits and estimate of economic impact]

INTRODUCTION AND OBJECTIVES

Antiproliferative drug-coated stents are a possible solution for post-angioplasty coronary restenosis. Here we analyze their efficacy, effectiveness and safety, and estimate the economic impact of their use in Spain.

MATERIAL AND METHOD

Systematic review (meta-analysis) of the scientific evidence available up to January 2004, and analysis of hospital costs within a 1-year time horizon.

RESULTS

We identified 12 published studies (5 clinical series and 7 RCTs) comparing coated stents (sirolimus or paclitaxel) with conventional stents in patient with de novo single lesions < 30 mm in 2.5-3.5 mm vessels. In nearly all cases the rates of angiographic restenosis and major adverse cardiac events were lower in the coated stent group after 6-12 months. Meta-analysis showed a 69% decrease in revascularization rate (RR=0.31; 95%CI, 0.19-0.51). For every 1000 patients with de novo lesions, the use of a coated stent involved an additional average cost of Euro 818718. The estimated neutral price of a new stent was Euro 1448 at a market price per unit of Euro 2000.

CONCLUSIONS

At 12-month follow-up, sirolimus- or paclitaxel-eluting stents were effective and safe in patients with de novo lesions and low or medium risk of restenosis. At current market prices, the widespread use of these stents would involve an increase in health care expenditure for the different sensitivity scenarios we evaluated. More studies are needed to specify the type of patients and lesions likely to obtain the greatest clinical benefit.