Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost–utility study
- 1University of Liverpool Management School, Liverpool, UK
- 2Cardiothoracic Centre Liverpool NHS Trust, Liverpool, UK
- 3Prescribing 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
- Accepted 21 March 2005
- Published Online First 14 April 2005
Abstract
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.
- 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
Footnotes
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Published Online First 12 May 2005
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Funding: An early version of this work was funded as part of an appraisal on behalf of the National Institute for Clinical Excellence. AB is partly funded by project funds from the NHS HTA programme. TW is Director of the NHS HTA programme. Neither NICE nor NCCHTA had any influence over the design, analysis, or reporting of this study.
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Competing interests: none
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Ethics approval: no separate ethics approval required.
Contributors: AB carried out the economic analysis and drafted the paper. ADG extracted and analysed CTC audit data, carried out proportional hazards risk modelling, and revised the draft paper. TW conceived the study, contributed to its design, and participated in revising the draft paper. NP and RAP provided specialist cardiological advice to the study and participated in revising the draft paper. AB is guarantor for the paper.
