Halving DES Use in Low-Risk Patients Could Save $200 Million Annually

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Drug-eluting stent (DES) use in the United States varies widely among physicians, showing only a modest correlation with restenosis risk, according to a registry study published online July 9, 2012, ahead of print in the Archives of Internal Medicine. The investigators suggest that less DES use in low-risk patients has the potential for substantial cost savings while minimally increasing restenosis events.

The data were originally presented at the annual American Heart Association Scientific Sessions in November 2011.

Robert W. Yeh, MD, MSc, of Massachusetts General Hospital (Boston, MA), and colleagues analyzed 1,506,758 PCI admissions from 1,119 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI registry from January 2004 through September 2010. Overall, 43.0% of patients were predicted to be at low risk for TVR, while 43.8% were deemed to be at moderate risk and 13.2% at high risk.

DES were implanted in 76.9% of the study population. Among the 2,715 physicians performing at least 75 procedures per year between July 2009 through September 2010, DES use ranged from 2% to 100%.

The median predicted TVR risk for the overall cohort was 11%. DES use varied only slightly according to risk. Rates were:

• Low risk: 73.9%
• Moderate risk: 78.0%
• High risk: 83.2%

There was a 0.53% relative increase in the rate of DES use for each 1% increase in the predicted risk of TVR with BMS. In addition, despite an overall decline in DES use over time (30% after October 2006, when concerns over late stent thrombosis were raised), the relationship between TVR risk and DES use was modest both before October 2006 (RR 1.0020; 95% CI 1.0016-1.0025) and after (RR 1.0086; 95% CI 1.0082-1.0089; P < 0.01 for interaction).

Using a validated model, the researchers calculated that a 50% reduction in DES use only among patients at low TVR risk would yield a net savings of $204,654,000 per year, despite a modest estimated increase in repeat procedures due to TVR (absolute increase in TVR rate 0.50%; 95% CI 0.49%-0.51%).

A ‘Multifactorial’ Issue

In a telephone interview with TCTMD, Dr. Yeh said both the total number of patients in the low-risk category and the percentage of them who still received DES were surprising. In addition, the reason behind the numbers is “multifactorial.”

Physicians want to provide the best possible care for their patients, but “there’s this underlying presumption that drug-eluting stents would be preferred by patients because they are the newest and best available technology,” he observed. In order to actually offer the best care for patients, he added, physicians are challenged to bring risk-stratification into routine practice.

“It’s not easy for clinicians to stop in the middle of the day and apply a risk-prediction model to our individual patients to see what their precise risk of restenosis is,” Dr. Yeh explained, noting that often there is not enough time to have appropriate conversations about such issues with patients.

In addition, “not having a full appreciation of the downsides of prolonged dual antiplatelet therapy” probably contributes to overuse of DES in patients who might not benefit greatly from the technology, he said.

Making progress requires raising awareness of the problem, Dr. Yeh observed. “We’re not advocating that everyone with a low risk of restenosis should get a bare-metal stent,” he said  “[But] the patient should be aware of the risks and benefits of the stent they get, that there is a decision to be made, and that that should be a shared decision between the patient and the physician.”

Not Necessarily a ‘No Brainer’

In an accompanying editorial, Peter W. Groeneveld, MD, MS, of the University of Pennsylvania School of Medicine (Philadelphia, PA), writes that since “TVR typically has only modest impact on patients’ quality of life and negligible impact on lifespan, it is reasonable to conclude that such an economic tradeoff should be a societal ‘no brainer.’”

Dr. Groeneveld notes that in the United Kingdom, DES usage is much lower than in the United States. “There is little evidence to suggest that British patients with coronary artery disease were treated suboptimally by their physicians, but it is likely that on average they were treated more inexpensively,” he writes.

Dr. Groeneveld agrees with Dr. Yeh’s assessment that “indiscriminate” DES use in the United States is encouraged by many factors. First, “some physicians may be convinced that the superiority of the DES to BMS . . . essentially includes every scenario in which the DES is not absolutely contraindicated.” Also, “some clinicians may favor a particular treatment option after a prior adverse experience with the alternative, while other physicians may choose a DES in anticipation of future regret and/or concerns about future accusations of malpractice.”

He also suggests that new technology is appealing “for its own sake,” and physicians might want to assure their patients that they are receiving the “most cutting-edge technology.” Lastly, he writes that physicians are influenced by their peers, who are most likely using DES.

Too Much New Technology?

In a telephone interview with TCTMD, David E. Kandzari, MD, of the Piedmont Heart Institute (Atlanta, GA), basically agreed with the editorial. But he cautioned that it is much more difficult to make pronouncements regarding the need for value-based decision making when directly engaged in patient care. “It’s easy to dictate which products someone should have—unless you’re the consumer [who] might want the best,” he commented.

Dr. Kandzari also criticized the length of the study period since DES use was highest before 2006 and faced intense scrutiny from 2006 to 2007. “So to look at an average really doesn’t detail the full story,” he noted.

Also, while “the [cost-effectiveness] model accounts for costs of repeat procedures, it doesn’t account for the potential sequelae of myocardial infarction that could occur with restenosis or for patient quality of life associated with angina,” he said. “Neither of those should be discounted when trying to make a blanket statement about the type of stents that should be utilized.”

Lastly, Dr. Kandzari questioned whether clinicians are focusing on the proper issue. “As the costs of drug-eluting stents and drugs like clopidogrel continue to erode, this further offsets the cost equation in favor of drug eluting stents such that achieving cost savings may not be as great as what’s being proposed,” he observed. “As novel drug-eluting stents are introduced, perhaps the better question is not whether we should be substituting drug-eluting stents for bare-metal stents but whether new or more expensive drug-eluting stents and antiplatelet therapies are as necessary.”

Study Details

Patients considered at high risk for TVR were more likely to be older, male, and have diabetes, chronic kidney disease, and prior PCI. They were also more likely to present with stable angina rather than an unstable coronary syndrome, and were more likely to have severe 3-vessel CAD, with smaller-diameter vessels and longer lesions.

 

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Sources:
1. Amin AP, Spertus JA, Cohen DJ, et al. Use of drug-eluting stents as a function of predicted benefit: Clinical and economic implications of current practice. Arch Intern Med. 2012;Epub ahead of print.

2. Groeneveld PW. How drug-eluting stents illustrate our health system’s flawed relationship with technology: Value lost. Arch Intern Med. 2012;Epub ahead of print.

 

• Drs. Groeneveld and Kandzari report no relevant conflicts of interest.

 

Related Stories:

• ‘Judicious Use’ of DES in Low-Risk Patients Could Save Over $200 Million per Year
• Model Tries to Simplify Choice Between Drug-Eluting, Bare-Metal Stents
• DES Not Cost Effective When Late Thrombosis, Extended Clopidogrel Factored In

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