Dollars and Stents: The Economics of Drug-Eluting Stents

Variations in the use of an innovative technology by payer: the case of drug-eluting stents

BACKGROUND

Despite receiving identical reimbursement for treating heart disease patients with bare metal stents (BMS) or drug-eluting coronary stents (DES), cardiologists' use of the new technology (DES) may have varied by patient payer type as DES diffused. Payer-related factors that differ between hospitals and/or differential treatment inside hospitals might explain any overall differences by payer type.

OBJECTIVES

To assess the association between payer and DES use and to examine between-hospital and within-hospital variation in DES use over time.

METHODS

We conducted a retrospective analysis of 4.1 million hospitalizations involving DES or BMS from 2003 to 2008 Nationwide Inpatient Sample. We estimated hybrid-fixed effects logit models and calculated the adjusted within-quarter, cross-payer differences in DES use.

RESULTS

Coronary stent patients with Medicaid or without insurance were significantly less likely to receive DES than were patients with private insurance throughout the study period. The differences fluctuated over time as the popularity of DES relative to BMS increased and decreased. The within-hospital gaps paralleled the overall differences, and were largest in Q3 2003 (Medicaid: 11.9, uninsured: 10.9% points) and Q4 2008 (Medicaid: 12.8, uninsured: 20.7% points), and smallest in Q4 2004 (Medicaid: 1.4, uninsured: 1.1% points). The between-hospital adjusted differences in DES use by payer were small and rarely significant.

CONCLUSIONS

We found substantial differences in DES use by payer within hospitals, suggesting physicians selected the new technology for patients in a manner associated with patients' payer type.

Drug‐eluting versus third‐generation bare metal stents: The US strategy

Drug-eluting stents have rapidly come to dominate the field of coronary intervention, constituting 85% of the US market just one year after introduction. The current utilization of bare metal stents in coronary intervention in the US is quite limited. This article will review technological advances in third-generation bare metal stents, which optimize procedural performance by means of improved flexibility, lower crossing profile, and thinner struts while maintaining fluoroscopic visibility and may portend a continued role for bare metal stents in some settings. This article will review data pertaining to outcomes with new generation bare metal stents and discuss current options for utilization of drug eluting stents versus bare metal stents in the US.

The costs and quality-of-life outcomes of drug-eluting coronary stents: a systematic review

OBJECTIVES

While the efficacy of drug-eluting coronary stents (DES) has been demonstrated by several clinical trials, the impact of DES on health-care costs and recipient quality of life (QOL) is controversial. We performed a systematic review of the published literature on DES costs and the QOL effects of restenosis and target vessel revascularization (TVR).

METHODS

Among 536 potential articles initially identified by a broad search, 12 publications ultimately met inclusion criteria. Data were independently abstracted, evaluated for quality and relevance, and summarized by two reviewers. Excessive heterogeneity among these studies prevented formal meta-analysis, thus a narrative synthesis of the literature was performed.

RESULTS

In four economic studies, DES recipients had 1,600 dollars-3,200 dollars higher up-front costs than recipients of bare metal stents, but the differences in total costs after 1 year were less pronounced (200 dollars-1,200 dollars), and estimates of the average cost of an avoided revascularization ranged widely (1,800 dollars-36,900 dollars). All eight QOL studies indicated that restenosis was associated with lower QOL, but only two studies quantified this in terms of quality-adjusted life years (QALYs), with estimates ranging from 0.06 to 0.08. An additional study estimated that the median willingness to pay to prevent restenosis was 2,400 dollars-3,600 dollars.

CONCLUSIONS

There is a lack of convergence in the literature on the cost of DES in avoiding TVR. There is more agreement that the average QALY benefit of an avoided revascularization is 0.04-0.08. This implies that use of DES in patients where the average cost per avoided revascularization exceeds 8,000 dollars may be less likely to be cost-effective.