Feature: Looking to transform costs? Start with DES use
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During the study, researchers from Massachusetts General Hospital (MGH) in Boston questioned whether DES is typically used in patients at a higher risk of target vessel revascularization (TVR) and evaluated whether reduced DES use in lower risk TVR patients would be more cost-effective.
Robert W. Yeh, MD, MSc, and colleagues looked at more than 1.5 million PCI procedures within the National Cardiovascular Data Registry CathPCI Registry that took place between 2004 and 2010 and estimated the one-year TVR risk with BMS using a risk-prediction model.
“We are trying to encourage physicians to think more about who can benefit from certain technologies and therapies during PCI," Yeh, an interventional cardiologist at MGH, told Cardiovascular Business. “We have been involved in developing risk-prediction models that can help identify those patients who can derive the greatest benefit.”
The total estimated costs associated with DES use were tapped at $1.57 billion between 2002 and 2006. “It’s one thing to say that drug-eluting stent use costs a lot, but it’s another to actually understand whether we are using drug-eluting stents in a cost-effective manner," Yeh said.
“Patients may opt not to have a drug-eluting stent if they knew all the information and knew how much they would benefit from them,” he added.
While high-risk TVR patients may benefit most from DES use, Yeh and colleagues wrote that DES are more expensive than BMS and prolong dual antiplatelet therapy, which increases costs, bleeding risk and complications.
To break down the actual benefits of DES, Yeh et al developed a risk-prediction model to classify patients based on their risk of developing a restenosis.
“We looked at whether patients at high-risk of restenosis, those being the ones that were more likely to benefit from DES, were selectively receiving drug-eluting stents,” Yeh says. “What we found was that the predicted risk of restenosis had very little to do with a patient's likelihood of receiving a drug-eluting stent.”
In fact, Yeh et al found a marked variation in physicians’ DES use across the country (between 2 and 100 percent). Additionally, Yeh et al reported DES use to be high among all risk groups: 73.9 percent for those with a TVR risk of less than 10 percent; 78 percent for those with a 10 to 20 percent TVR risk; and 83.2 percent for those with a TVR risk of greater than 20 percent.
“We hope clinicians and patients think more about their likelihood of benefiting from a drug-eluting stent,” Yeh added. He said that the risk-prediction model used within the study has been made publicly available and that more tactics are being looked at to use these risk instruments in routine clinical care.
“Physicians should engage patients in the decisions surrounding these PCI procedures so that they are fully aware of how they might benefit and what the potential downfalls could be of the therapies they receive.”
Yeh said that if DES use was reduced by 50 percent among low-risk TVR patients, the U.S. healthcare system could save an estimated $205 million per year, or $34,109 per 100 PCIs performed compared with current practice.
“If these things are done more consistently in the cath labs around the country than there will be more opportunity to improve patient-centered care and reduce cost,” Yeh concluded.
Because of the costs associated with DES technologies, Yeh et al offered that there is a great opportunity to tailor DES use to those with the greatest potential to receive benefit. Despite the high costs associated with DES use, Yeh et al said that the risks associated with dual-antiplatelet therapy (DAPT) discontinuation, including an exposure to increased risk of stent thrombosis, could inspire many low-risk TVR patients to favor PCI with a bare-metal stents.
But how did DES use become such an expensive issue? Editorialist Peter W. Groeneveld, MD, MS, associate professor of medicine at the University of Pennsylvania in Philadelphia, told Cardiovascular Business that it may be partly due to off-label use. "There were situations that probably did not call for this type of technology," he said.
Groeneveld said that the U.S. healthcare system must re-examine its relationship with technology, as currently it is flawed. When a new technology comes on the market, physicians use it in the way that it is designed to be used and many situations that it is not designed to be used. "Off-label usage does not help patients and it just ends up costing the health system money," he added.
"The drug-eluting stent story reveals how the healthcare system does not adopt new technologies in a smart fashion," he said. "We let enthusiasm be the driver. And while it's great to be enthusiastic about newer technologies, it is also helpful to be wise about its limitations."
He added that education will be the key to transforming this process. "We must ask ourselves when a new drug, device or procedure comes on the market whether physicians know the science behind the new products." Additionally, he said that physicians face little economic consequence for the decisions they make. "If the doctor doesn't have any impedance to pick an older treatment, he or she will choose the newer one."
He added that some barriers must be put in place to help economically stabilize the country. "We are rapidly running out of the funds to pay for all of the healthcare service that we have promised. We are going to have to be smarter about our decisions," Groeneveld summed.