Cost-effectiveness Of Drug-eluting Stents Research Articles

Cost-Effectiveness of Drug-Eluting Stents in Elderly Patients With Coronary Artery Disease: The SENIOR Trial

BackgroundElderly patients receive bare metal stents instead of drug-eluting stents (DES) to shorten the duration of dual antiplatelet therapy (DAPT). The SENIOR trial compared outcomes between these 2 types of stents combined with a short duration of DAPT. A significant decrease in the number of patients with at least 1 major adverse cardiac and cerebrovascular event (MACCE) was noted in the DES group. ObjectivesThe objective of this article was to perform an economic evaluation of the SENIOR trial. MethodsThis evaluation was performed separately in 5 participating countries using pooled patient-level data from all study patients and country-specific unit costs and utility values. Costs, MACCEs, and quality-adjusted life-years (QALYs) were calculated in both arms at 1 year, and an incremental cost-effectiveness ratio was estimated. Uncertainty was explored by probabilistic bootstrapping. ResultsA total of 1200 patients underwent randomization. The average total cost per patient was higher in the DES group. The number of MACCEs and average QALYs were not statistically different between the 2 groups. The 1-year incremental cost-effectiveness ratio for each country of reference ranged from €13 752 to €20 511/MACCE avoided and from €42 835 to €68 231/QALY gained. The scatter plots found a wide dispersion, reflecting a large uncertainty surrounding the results. But in each country studied, 90% of the bootstrap replications indicated a higher cost for greater effectiveness for the DES group. Assuming a willingness to pay of €50 000/QALY, there was between a 40% and 50% chance that the use of DES was cost-effective in 4 countries. ConclusionThe use of DES instead of bare metal stents combined with a short duration of DAPT in elderly patients induced higher cost for greater effectiveness in each of the 5 countries studied.

Contemporary Context of Drug-Eluting Stents in Brazil: A Cost Utility Study.

Although drug-eluting stents (DES) have been widely incorporated into clinical practice in developed countries, several countries restrict their use mainly because of their high cost and unfavorable incremental cost-effectiveness ratios (ICER). To evaluate the cost-effectiveness of DES in comparison with bare-metal stents (BMS) for treatment of coronary artery disease (CAD). Markov model. Published literature, government database, and CAD patient cohort. Single-vessel CAD patients. One year and lifetime. Brazilian Public Health System (SUS). Six strategies composed of percutaneous intervention with a BMS or 1 of 5 DES (paclitaxel, sirolimus, everolimus, zotarolimus, and zotarolimus resolute). Cost for target vessel revascularization avoided and cost for quality-adjusted life year gained. In the short-term analysis, sirolimus was the most effective and least costly among DES (ICER of I$20,642 per target vessel revascularization avoided), with all others DES dominated by sirolimus. Lifetime cumulative costs ranged from I$18,765 to I$21,400. In the base case analysis, zotarolimus resolute had the most favorable ICER among the DES (ICER I$62,761), with sirolimus, paclitaxel, and zotarolimus being absolute dominated and everolimus extended dominated by zotarolimus resolute, although all the results were above the willingness-to-pay threshold of 3 times the gross domestic product per capita (I$35,307). In deterministic sensitivity analysis, results were sensitive to cost of DES, number of stents used per patient, baseline probability, and duration of stent thrombosis risk. The probabilistic sensitivity analysis demonstrated a probability of 81% for BMS being the strategy of choice, with 9% for everolimus and 9% zotarolimus resolute, at the willingness-to-pay threshold. DES is not a good value for money in SUS perspective, despite its benefit in reducing target vessel revascularization. Since the cost-effectiveness of DES is mainly driven by the stents' cost difference, they should cost less than twice the BMS price to become a cost-effective alternative.

Using meta-regression analyses in addition to conventional systematic review methods to examine the variation in cost-effectiveness results - a case study.

BackgroundSystematic reviews of cost-effectiveness analyses summarize results and describe study characteristics. Variability in the study results is often explained qualitatively or based on sensitivity analyses of individual studies. However, variability due to input parameters and study characteristics (e.g., funding or study quality) is often not statistically explained. As a case study, a systematic review on the cost-effectiveness of drug-eluting stents (DES) versus bare-metal stents (BMS) using meta-regression analyses is performed to explore the usefulness of such methods compared with conventional review methods.MethodsWe attempted to identify and review all modelling studies published until January 2012 that compared costs and consequences of DES versus BMS. We extracted general study information (e.g., funding), modelling methods, values of input parameters, and quality of the model using the Philips et al. checklist. Associations between study characteristics and the incremental costs and effectiveness of individual analyses were explored using regression analyses corrected for study ID.ResultsSixteen eligible studies were identified, with a combined total of 508 analyses. The overall quality of the models was moderate (59 % ± 15 %). This study showed associations (e.g., type of lesion) that were expected (based on individual studies), however the meta-regression analyses revealed also unpredicted associations: e.g., model quality was negatively associated with repeat revascularizations avoided.ConclusionsMeta-regressions can be of added value, identifying significant associations that could not be identified using conventional review methods or by sensitivity analyses of individual studies. Furthermore, this study underlines the need to examine input parameters and perform a quality check of studies when interpreting the results.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1230-4) contains supplementary material, which is available to authorized users.

Cost Effectiveness of Drug-Eluting Stents as Compared With Bare Metal Stents in Patients With Coronary Artery Disease

The aim of this study was to estimate the incremental cost effectiveness of replacing bare metal stents (BMS) by drug-eluting stents (DES) when using trial data and registry data. We developed a Markov model (model of cost effectiveness of coronary artery disease) in which 60-year-old patients started by undergoing percutaneous coronary intervention for acute or subacute coronary artery disease. The patients are followed until death or 100 years of age. Data on the occurrence of events (revascularization, acute myocardial infarction, and death) were based on Scandinavian registry data. Separate analyses were conducted with data on effectiveness based on randomized controlled trials and patient registries. On using trial data, it was found that sirolimus-eluting stents (SES) yield 0.003 greater life expectancy and $3300 lower costs than do BMS (dominant strategy). Paclitaxel-eluting stents (PES) yield 0.148 more life years than do SES at additional lifetime costs of $2800 ($21,400 per life year gained). On using registry data, the cost per life year gained was found to be $4900 when replacing BMS with DES. Probabilistic sensitivity analyses, on the other hand, indicate that PES only has a 50%-75% probability of being cost effective, regardless of the type of effectiveness data. DESs are cost effective with current willingness to pay for life year gains. Whether PES or SES is the most effective DES remains uncertain.

PCV108 - Cost-Effectiveness of Drug-Eluting Stents Versus Bare Metal Stents in Egyptian Diabetic Patients

Cost-effectiveness of Drug eluting stents (DES) versus bare metal stents (BMS) in Egyptian diabetic patients with chronic coronary artery disease from a patient perspective was evaluated over a time horizon of 3 years. A cohort Markov process model with five health states: stent, coronary artery bypass surgery (CABG), non-fatal myocardial infarction (MI), percutaneous coronary intervention (PCI) and death was derived from published data. The transition probabilities from the index procedure to death, MI, PCI, and CABG were derived from an updated, previously published meta-analysis of RCTs comparing DES with BMS in patients with coronary artery disease. Relative risk reduction, restenosis risks, mortality rates, utilities were derived using published sources. Direct Medical costs were obtained from 4 top-rated cardiology hospitals in Egypt. All costs and effects were discounted at 3.5% annually. All costs were reported in Egyptian pounds of the financial year 2013. Deterministic sensitivity analysis was conducted. In the overall population, total costs for DES and BMS were 20,664 EGP and 11,957 EGP respectively. Total QALYs for DES and BMS were 2.26 and 2.05 respectively. The incremental cost-effectiveness ratio (ICER) for DES versus BMS was 41,616 EGP/QALY. DES is cost effective because it is less than 3 times GDP/capita in Egypt (57,566 EGP). Results between DES and BMS were most sensitive to the Mortality rate of both DES and BMS. World Health Organization recommends that interventions that cost more than 3 times GDP/capita for one Disability Adjusted Life Year (DALY) avoided should not be reimbursed. Despite DALY is different from QALY but we can assume that they are similar to be able to put a value on the outcome. DES represents a good value for money compared to BMS in Egyptian diabetic patients with chronic coronary artery disease.

Cost Effectiveness of Drug-Eluting Stents in Acute Myocardial Infarction Patients in Germany

The high number of patients with acute myocardial infarction (AMI) has facilitated greater research, resulting in the development of innovative medical devices. So far, results from economic evaluations that compared drug-eluting stents (DES) and bare-metal stents (BMS) have not shown clear evidence that one intervention is more cost effective than the other. The aim of this study was to measure the cost effectiveness of DES compared with BMS in routine care. We used administrative data from a large German sickness fund to compare the costs and effectiveness of DES and BMS in patients with AMI. Patients with hospital admission after AMI in 2004 and 2005 were followed up for 1 year after hospital discharge. The cost of treatment and survival after 365 days were compared for patients treated with DES and BMS. We adjusted for covariates defined according to the Ontario Acute Myocardial Infarction Mortality Prediction Rules using propensity score matching. After matching, we calculated incremental cost-effectiveness ratios (ICERs) by (i) using sample means based on bootstrapping procedures and (ii) estimating generalized linear mixed models for costs and survival. After propensity score matching, the sample included 719 patients treated with DES and 719 patients treated with BMS. A comparison of sample means resulted in average costs of € 12 714 and € 11 714 for DES and BMS, respectively, in 2005 German euros. Difference in 365-day survival was not statistically significant (700 patients with DES and 701 with BMS). The ICER of DES versus BMS was -€ 718 709 per life saved. Bootstrapping resulted in DES being dominated by BMS in 54.5% of replications and DES being a dominant strategy in 2.7% of replications. Results from regression models and sensitivity analyses confirm these results. Treatment with DES after admission with AMI is less cost effective than treatment with BMS. Our results are in line with other cost-effectiveness analyses that used administrative data, i.e. under routine care conditions. However, our results do not preclude that DES may be cost effective in specific patient subgroups.

Cost-effectiveness of Drug-eluting Stents in Patients With Stable Coronary Artery Disease

Drug-eluting stents (DESs) have been shown to reduce in-stent restenosis and target vessel revascularization (TVR) in large clinical trials. We conducted this study to elucidate the differences in the cost and clinical outcome of DESs and bare metal stents (BMSs). We retrospectively analyzed the clinical data and costs of patients with stable angina treated with coronary stents from September 2003 to January 2005 at the National Taiwan University Hospital, Taipei, Taiwan. We enrolled 186 patients treated with DESs and 194 patients treated with BMSs. The use of DESs is associated with a lower rate of TVR compared with that with BMSs (12%vs. 22%, p = 0.011). Compared with the BMS group, the overall costs were significantly higher in the DES group (NT$352,495 ± 140,408 vs. NT$298,947 ± 131,289, p<0.001). The incremental cost to avoid one TVR at 2 years was NT$546,444 (95% confidence interval: NT$151,071-2,565,793). The use of DESs reduces the rate of TVR at 2 years after intervention, but is probably not cost-effective compared with BMSs in patients with stable coronary artery disease.

Cost-Effectiveness of Drug-Eluting Stents in Large (≥3.5mm) Coronary Arteries

Cost-Effectiveness of Drug-Eluting Stents in Large (≥3.5mm) Coronary Arteries

Cost-Effectiveness of Drug-Eluting Stents in a US Medicare Setting: A Cost-Utility Analysis with 3-Year Clinical Follow-Up Data

Background There is only limited information about cost-effectiveness of drug-eluting compared with bare metal stents (BMS) over a time horizon of more than 1 year. Methods and Results We developed a Markov model based on clinical outcome data from a meta-analysis including 17 randomized controlled trials comparing drug-eluting versus BMS with a minimum follow-up of 1 (n = 8221) and a maximum follow-up of 3 years (n = 4105) in patients with chronic coronary artery disease. Costs were obtained as reimbursement rates for diagnosis related groups from the US Centers for Medicare and Medicaid Services. All costs and effects were discounted at 3% annually. All costs are reported in US dollars of the financial year 2007. The incremental effects are 0.002 (95% confidence interval −0.039 to 0.041) quality-adjusted life-years (QALYs) for the sirolimus- and −0.001 (−0.040 to 0.038) QALYs for the paclitaxel-eluting stents (PES). The incremental costs are $2790 for the sirolimus- and $3838 for the PES. The incremental cost-effectiveness ratio is >$1,000,000 per QALY for the sirolimus-eluting stent. PES are dominated by BMS (i.e., less effective and more costly). Among various sensitivity analyses performed, the model proved to be robust. Conclusions Our analysis from a US Medicare perspective suggests that drug-eluting stents are not cost-effective compared with BMS when implanted in unselected patients with symptomatic ischemic coronary artery disease.

Cost Effectiveness of Drug-Eluting Stents In Belgian Practice

There has been a steep increase in the number of percutaneous coronary intervention procedures performed for coronary heart disease since their introduction about 30 years ago. Recently, the use of drug-eluting stents (DES) compared with the original bare metal stents (BMS) has increased in many countries. To assess the cost effectiveness of DES versus BMS in a real-world setting from the Belgian healthcare payer perspective. We developed a decision analysis model to estimate incremental costs (year 2004 or 2007 values [depending on the underlying variable]) and effectiveness. Incremental effectiveness was calculated by combining relative benefits from published meta-analyses with real-world observations from a Belgian registry. Probabilistic modelling and sensitivity analyses were performed. The model had a 1-year time horizon. Sixteen sub groups were created based on the following characteristics: initial stent type, diabetic status, complex lesion and multi-vessel disease. Scenario analyses were performed for the influence on reinterventions and the duration of clopidogrel use. In each analysis, 1000 Monte Carlo simulations were performed. The incremental costs for switching from BMS to DES are substantial (approximately euro1000), while the benefits, expressed as QALYs, are extremely small (on average <0.001 QALYs gained). This led to very high incremental cost-effectiveness ratios: over euro860 000 per QALY gained in all subgroups and scenario analyses. Comparing DES with BMS, no life-years are gained and small quality-of-life improvements are achieved for short periods, resulting in a high likelihood that DES are not cost effective. When there is competition for scarce resources this should be considered when deciding on the reimbursement of this technology.

Cost-effectiveness analyses of drug eluting stents versus bare metal stents: A systematic review of the literature

Drug eluting stents (DES) used to treat coronary lesions reduce rates of in-stent restenosis and therefore the need for repeat revascularization compared to bare metal stents (BMS). DES, however, are considerably more expensive than BMS. We evaluated whether DES are a cost-effective alternative for BMS. Reports of Health Technology Assessment agencies were assessed and a systematic review of economic evaluations comparing DES with BMS was performed. Nineteen full economic evaluations were identified. Some studies indicate that DES may be cost-effective or even cost-saving in specific patients, when used for coronary lesions with a high propensity of restenosis such as long lesions, lesions in narrow vessels, or in patients with diabetes. Other studies mention DES is not cost effective at all with ICERs of more than 200,000 Canadian dollar per QALY gained. One of the main determining factors is the influence of protocol mandated angiographic follow-up in RCTs. The risk for a re-intervention using BMS ranges from 5% to 14% in registries and is much smaller than reported in RCTs (up to 30%). As a result, the absolute reduction in repeat revascularization by DES compared to BMS is smaller in real life. Moreover, using DES instead of BMS does not increase survival or decrease myocardial infarctions. The combination of (a) a higher cost (>euro700) for DES versus BMS; (b) no life-years gained; (c) a relatively small absolute reduction in repeat procedures; and (d) a small improvement in QoL for a short period (less than 0.15 during the first month after the re-intervention), results in unfavourable cost-effectiveness ratios. Although several studies conclude that DES may be cost effective in large subgroups of patients, under real-world conditions, the cost-effectiveness of DES is unfavourable in comparison with BMS.

Cost Analysis of Sirolimus-Eluting Stents in the Japanese Health Insurance System

The cost-effectiveness of drug-eluting stents (DES) has been evaluated in the United States and Europe, however, there is little information from Japan. The present study evaluated the cost-effectiveness of sirolimus-eluting stents (SES) in Japan. In-hospital and follow-up costs of 25 consecutive patients undergoing SES implantation in a de novo lesion were evaluated. A control group for comparison was composed of 25 consecutive patients undergoing bare metal stent (BMS) implantation in a de novo lesion before the introduction of SES. There was no significant difference in resource use between the SES and BMS groups. Procedural cost (yen1,049,200 +/- 208,793 versus yen896,590 +/- 117,984, P = 0.01) was higher in the SES group than in the BMS group because of the higher reimbursement price of SES (yen378,000 versus yen258,000). In-hospital cost (yen1,202,891 +/- 208,793 versus yen1,050,280 +/- 177,984, P < 0.01) was higher in patients treated with SES. Less target lesion revascularization (4% versus 20%, P = 0.2) in patients with SES reduced the difference; aggregate 1-year cost was not significantly different (yen1,479,481 +/- 284,343 versus yen1,463,640 +/- 495,803, P = 0.9). It is concluded that SES may be cost-effective even in Japan.

Cost-effectiveness of drug-eluting stents in patients at high or low risk of major cardiac events in the Basel Stent KostenEffektivitäts Trial (BASKET): an 18-month analysis

Our aim was to determine whether drug-eluting stents are good value for money in long-term, everyday practice. We did an 18-month cost-effectiveness analysis of the Basel Stent KostenEffektivitäts Trial (BASKET), which randomised 826 patients 2:1 to drug-eluting stents (n=545) or to bare-metal stents (281). We used non-parametric bootstrap techniques to determine incremental cost-effectiveness ratios (ICERs) of drug-eluting versus bare-metal stents, to compare low-risk (> or =3.0 mm stents in native vessels; n=558, 68%) and high-risk patients (<3.0 mm stents/bypass graft stenting; n=268, 32%), and to do sensitivity analyses by altering costs and event rates in the whole study sample and in predefined subgroups. Quality-adjusted life-years (QALYs) were assessed by EQ-5D questionnaire (available in 703/826 patients). Overall costs were higher for patients with drug-eluting stents than in those with bare-metal stents (11,808 euros [SD 400] per patient with drug-eluting stents and 10,450 euros [592] per patient with bare-metal stents, mean difference 1358 euros [717], p<0.0001), due to higher stent costs. We calculated an ICER of 64,732 euros to prevent one major adverse cardiac event, and of 40,467 euros per QALY gained. Stent costs, number of events, and QALYs affected ICERs most, but unrealistic alterations would have been required to achieve acceptable cost-effectiveness. In low-risk patients, the probability of drug-eluting stents achieving an arbitrary ICER of 10,000 euros or less to prevent one major adverse cardiac event was 0.016; by contrast, it was 0.874 in high-risk patients. If used in all patients, drug-eluting stents are not good value for money, even if prices were substantially reduced. Drug-eluting stents are cost effective in patients needing small vessel or bypass graft stenting, but not in those who require large native vessel stenting.

Economic evaluation of drug-eluting stents: A systematic literature review and model-based cost–utility analysis

The aim of this study was to systematically review economic analyses comparing drug-eluting stents (DES) to bare metal stents (BMS) in patients who undergo percutaneous coronary intervention to form an overall view about cost-effectiveness of DES and to construct a simple decision analysis model to evaluate the cost-utility of DES. Electronic databases searched from January 2004 to January 2006 were Cochrane Database of Systematic Reviews; DARE, HTA, EED (NHS CRD); MEDLINE(R) In-Process, Other Non-Indexed Citations, MEDLINE(R). References of the papers identified were checked. We included randomized controlled trials (RCT) or model-based cost-effectiveness analyses comparing DES to BMS in patients with coronary artery disease. The methodological quality of the papers was assessed by Drummond's criteria. Baseline characteristics and results of the studies were extracted and data synthesized descriptively. A decision tree model was constructed to evaluate the cost-utility of DES in comparison to BMS, where health-related quality of life was measured by the 15D. We identified thirteen good-quality economic evaluations. In two of these based on RCTs, DES was found cost-effective. In six studies, it was concluded that DES might probably be a cost-effective strategy in some circumstances, but not as a single strategy, and four studies concluded that DES is not cost-effective. One study did not draw a clear conclusion. In our analysis, the overall incremental cost-effectiveness ratio was Euros 98,827 per quality-adjusted life-years gained. Avoiding one revascularization with DES would cost Euros 4,794, when revascularization with BMS costs Euros 3,260. The evidence is inconsistent of whether DES would be a cost-effective treatment compared with BMS in any healthcare system where evaluated. A marked restenosis risk reduction should be achieved before use of DES is justifiable at present prices. When considering adoption of a new health technology with a high incremental cost within a fixed budget, opportunity cost in terms of untreated patients should be seriously considered as a question of collective ethics.

Drug-eluting stents

[One of the authors responds:] We appreciate the interest in our recent article.[1][1] We echo the concern of Liana Falcone and Navdeep Tangri that the cost-effectiveness of drug-eluting stents should be scrutinized; our desire to understand the variability in research conclusions prompted our

The cost-effectiveness of drug-eluting stents: a systematic review

Drug-eluting stents have been seen as an attractive alternative to bare-metal stents for percutaneous coronary interventions (PCIs) because of the decreased need for revascularization. However, comparative clinical trials have shown no difference in patient outcomes, and drug-eluting stents are considerably more expensive than their bare-metal counterparts. We conducted a systematic review of all published comparative cost-effectiveness analyses to identify the factors contributing to the heterogeneity of their conclusions. We retrieved all articles published between Jan. 1, 2000, and July 31, 2006, in which the cost-effectiveness, from a third-party payer perspective, of drug-eluting stents was compared with that of bare-metal stents for PCI in unrestricted patient populations. Electronic databases, Web sites from health technology assessment groups and references of identified articles were searched. Our outcome variable was whether the study's conclusions favoured widespread use of drug-eluting stents, as assessed by 4 independent reviewers. Study characteristics such as quality, funding source, country and year of publication were extracted. Two-by-2 tables and Fisher's exact test were used to study the association between covariates and the outcome variable. A classification and regression tree (CART) model was used for multivariate analysis. We identified 19 cost-effectiveness analyses. Ten were in favour of widespread use of drug-eluting stents, and 9 favoured more restrained use. Only 1 of 9 high-quality studies supported widespread use, as compared with 9 of 10 lower quality studies (p < 0.001). All of the 7 sponsored studies argued in favour of widespread use, as compared with 3 of the 12 studies without sponsorship (p = 0.003). Studies from the United States were more likely than those from other countries to endorse unlimited use (p = 0.032). A CART model with 2 covariates--study quality and sponsorship--provided the best fit (error rate 10.5%). Conclusions drawn by cost-effectiveness analyses of drug-eluting stents for PCI are associated with the study's quality, funding source and country of origin. Vigilance regarding these study characteristics is required when interpreting findings from cost-effectiveness analyses.

Cost-effectiveness of drug-eluting stents: real-world scrutiny of the BASKET trial of real-world usage

This editorial examines incremental cost-effectiveness analysis as a decision-making tool to guide the allocation of scarce financial resources. BASKET (Basel Stent Kosten Effektivitats Trial) evaluated the cost-effectiveness of drug-eluting stents in a real-world setting. Results of this study are examined in relation to similar assessments and alternative plausible assumptions are explored and presented in the context of real-world sensitivity analysis.

Lack of efficacy and cost-effectiveness of drug-eluting stents: reply

We agree with Lyratzopoulos that drug-eluting stents (DES) lack any survival benefit compared with bare-metal stents (BMSs) for patients with chronic coronary heart disease. In addition, we believe that the higher rate of intra-stent restonis associated with DES during longer periods of …

Lack of efficacy and cost-effectiveness of drug-eluting stents

The findings of the meta-analysis about the comparative efficacy of drug-eluting stents (DESs) compared with bare-metal stents (BMSs) by Nordmann et al .1 both re-affirm and enhance those observed in previous research. Katritsis et al .2 have also demonstrated the lack of any efficacy superiority of DES over BMS, during the relatively short-term follow-up of between six and 12 months from intervention. Unsurprisingly for a health intervention with questionable clinical efficacy, the cost-effectiveness ratios of the current practice of nearly routine use …

Controversy over cost effectiveness of drug-eluting stents

Controversy over cost effectiveness of drug-eluting stents