USE OF DRUG ELUTING STENTS AS A FUNCTION OF PREDICTED BENEFIT: CLINICAL AND ECONOMIC IMPLICATIONS OF CURRENT PRACTICE

Background: Benefits of drug-eluting stents (DES) in percutaneous coronary intervention (PCI) are greatest in those at the highest risk of target vessel revascularization (TVR). While DES reduce restenosis, they cost more than bare metal stents (BMS), and necessitate prolonged dual antiplatelet therapy (DAPT) that increases costs, bleeding risk, and risk of complications if DAPT is prematurely discontinued. Our objectives were to assess if DES are preferentially used in those with higher predicted TVR risk, and to estimate whether lower use of DES (50% less DES use among patients with low predicted TVR risk) would be more cost-effective as compared with the existing pattern of DES use. Methods: We analyzed ~1.5 million PCI procedures in the NCDR CathPCI registry from Apr 2003 - Sept 2010. We estimated 1-year TVR risk assuming PCI with BMS using a previously validated prediction model. The main outcome measures were the rate of DES use and projected annual US societal costs at one year after PCI. We assessed the association between TVR risk with BMS DES use, and performed cost-effectiveness analysis of a lower use of DES (50% less DES use among patients with low predicted TVR risk) vs. existing DES use. Results: There was marked variation in physicians' use of DES (range = 2-100%). DES use was relatively high across all categories of predicted TVR risk (73.9% in patients with TVR risk 20%), with a modest correlation between predicted TVR risk and DES use (RR 1.005/1% increase in predicted TVR risk [95% CI = 1.005, 1.006]). Reducing DES use by 50% among the lowest risk patients was projected to lower US healthcare costs by $205 million/year while increasing the overall TVR event rate by 0.5% (95% CI= 0.49%, 0.51%) in absolute terms. Conclusions: DES use in the U.S. varies widely among physicians, with only modest correlation to patients' risk of restenosis. Less DES use among patients with low risk of restenosis has the potential for significant cost savings for the US healthcare system, while minimally increasing restenosis events