INTERVENTIONAL CARDIOLOGY AND SURGERY

Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost–utility study

A Bagust¹, A D Grayson², N D Palmer², R A Perry², T Walley³

¹ University of Liverpool Management School, Liverpool, UK
² Cardiothoracic Centre Liverpool NHS Trust, Liverpool, UK
³ Prescribing Research Group, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK

Correspondence to:
Professor Adrian Bagust
University of Liverpool Management School, Chatham Street, Liverpool L69 7ZH, UK; A.Bagust{at}liv.ac.uk

Objective: To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK.

Design: Cost–utility analysis of audit based patient subgroups by means of a simple economic model.

Setting: Tertiary care.

Participants: 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002.

Main outcome measures: Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost–utility ratio and threshold price premium.

Results: Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non-elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost–utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be £112 (US$212, 162) (sirolimus stents) or £89 (US$167, 130) (paclitaxel stents).

Conclusions: At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

Abbreviations: ARTS, arterial revascularisation therapies study; BMS, bare metal stents; CABG, coronary artery bypass grafting; CTC, Cardiothoracic Centre; DES, drug eluting stents; ICER, incremental cost effectiveness ratio; PTCA, percutaneous transluminal coronary angioplasty; QALY, quality adjusted life year; RAVEL, randomised study with the sirolimus eluting Velocity balloon expandable stent in the treatment of patients with de novo native coronary artery lesions; SIRIUS, sirolimus eluting balloon expandable stent in the treatment of patients with de novo native coronary artery lesions; SoS, stent or surgery; TAXUS, treatment of de novo coronary disease using a single paclitaxel eluting stent; TVR, target vessel revascularisation

Keywords: drug eluting stents; cost–benefit analysis; percutaneous coronary intervention

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