The cost-effectiveness of guideline-driven use of drug-eluting stents: propensity-score matched analysis of a seven-year multicentre experience

Abstract

Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer.

Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with ‘0’, 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000–$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71–91%, ‘0’ indications, 49–67%, 1 indication, 56–82%, 2 indications, 70–90%, and ≥3 indications, 97–99%.

Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with ‘0’ indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.

Keywords:

• Drug-eluting stents
• bare-metal stents
• cost-effectiveness
• risk factors
• guidelines
• target-vessel revascularisation

Transparency

Declaration of funding

TVA was supported by the National Heart Foundation of Australia Postgraduate Research Scholarship [PC10M 5457] for her research. The Melbourne Interventional Group acknowledges funding from Abbott, Astra-Zeneca, Biotronik, Boston Scientific, Bristol-Myers Squibb, Cordis Johnson & Johnson, CSL, Medtronic, MSD, Pfizer, Sanofi- Aventis, Servier, Schering-Plough, and The Medicines Company. These companies do not have access to data and do not have the right to review manuscripts or abstracts before publication. SJD and CMR’s work is supported by National Health and Medical Research Council of Australia Grants. BPY was supported by a Hong Kong Research Grant Council General Research Fund.

Declaration of financial/other relationships

All authors declare no competing interests and take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. The authors report no relationships that could be construed as a conflict of interest. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

MIG Steering Committee: Professor Chris Reid, A/Professor Andrew Ajani, Professor Stephen Duffy, A/Prof David Clark, Dr Melanie Freeman, Dr Chin Hiew, Dr Nick Andrianopoulos, A/Prof Ernesto Oqueli, Ms Angela Brennan. The following investigators, data managers and institutions participated in the MIG Database: Alfred Hospital: SJ Duffy, JA Shaw, A Walton, A Dart, A Broughton, J Federman, C Keighley, C Hengel, KH Peter, D Stub, W Chan, S Nanayakkara, J O’Brien, L Selkrig, K Rankin, R Huntington, S Pally; Austin Hospital: DJ Clark, O Farouque, M Horrigan, J Johns, L Oliver, J Brennan, R Chan, G Proimos, T Dortimer, B Chan, R Huq, D Fernando, M Yudi, K Charter, L Brown, A AlFiadh, J Ramchand, S Picardo; Ballarat Base Hospital: E Oqueli, A Sharma, C Hengel, N Ryan, T Harrison, C Barry; Box Hill Hospital: M Freeman, L Roberts, A Teh, M Rowe, G Proimos, Y Cheong, C Goods, D Fernando, J Ramzy, A Kosky, P Venkataraman; Monash University: C Reid, N Andrianopoulos, AL Brennan, D Dinh, BP Yan; Royal Melbourne Hospital: AE Ajani, R Warren, D Eccleston, J Lefkovits, R Iyer, R Gurvitch, W Wilson, M Brooks, S Biswas, J Yeoh; University Hospital, Geelong: C Hiew, M Sebastian, T Yip, M Mok, C Jaworski, A Hutchison, M Turner, B Khialani, B McDonald, R Pavletich. We also sincerely thank Mr. Marco Luthe, former Information Manager of Clinical Costing, at the Alfred Hospital’s Clinical Performance Unit, for his support with collecting clinical costing data for this project and interpreting this data.