Percutaneous coronary intervention with second-generation drug-eluting stent versus bare-metal stent: Systematic review and cost–benefit analysis

• Published in: PloS one Vol. 12; no. 5; p. e0177476
• Main Authors: Poder, Thomas G., Erraji, Jihane, Coulibaly, Lucien P., Koffi, Kouamé
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 12.05.2017; Public Library of Science (PLoS)
• Subjects: Analysis; Angioplasty; Arbitration; Attenuation; Cardiology; Cardiovascular disease; Chromium; Circulation; Clinical outcomes; Clinical trials; Cobalt; Comparative analysis; Computer programs; Coronary artery; Coronary artery disease; Coronary vessels; Cost benefit analysis; Cylinders; Data processing; Documents; Drug delivery; Drug-Eluting Stents - economics; Economic aspects; Effectiveness; Filters; Finite element method; Health aspects; Health risks; Heart; Heart attacks; Heart diseases; Humans; Hyperplasia; Implants; Language; Libraries; Literature reviews; Medicine and Health Sciences; Meta-analysis; Mortality; Myocardial infarction; Paclitaxel; Patients; People and Places; Percutaneous Coronary Intervention - economics; Physical Sciences; Protocol (computers); Quality control; Rapamycin; Research and Analysis Methods; Restenosis; Risk factors; Safety; Stainless steel; Stents; Stents - economics; Stochastic models; Studies; Surgical implants; Technology assessment; Thromboembolism; Thrombosis; Vascularization; Websites; Quebec; Canada; Quebec Canada
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0177476

Drug-eluting stents (DESs) were considered as ground-breaking technology promising to eradicate restenosis and the necessity to perform multiple revascularization procedures subsequent to percutaneous coronary intervention. Soon after DESs were released on the market, however, there were reports of a potential increase in mortality and of early or late thrombosis. In addition, DESs are far more expensive than bare-metal stents (BMSs), which has led to their limited use in many countries. The technology has improved over the last few years with the second generation of DESs (DES-2). Moreover, costs have come down and an improved safety profile with decreased thrombosis has been reported. Perform a cost-benefit analysis of DES-2s versus BMSs in the context of a publicly funded university hospital in Quebec, Canada. A systematic review of meta-analyses was conducted between 2012 and 2016 to extract data on clinical effectiveness. The clinical outcome of interest for the cost-benefit analysis was target-vessel revascularization (TVR). Cost units are those used in the Quebec health-care system. The cost-benefit analysis was based on a 2-year perspective. Deterministic and stochastic models (discrete-event simulation) were used, and various risk factors of reintervention were considered. DES-2s are much more effective than BMSs with respect to TVR rate ratio (i.e., 0.29 to 0.62 in more recent meta-analyses). DES-2s seem to cause fewer deaths and in-stent thrombosis than BMSs, but results are rarely significant, with the exception of the cobalt-chromium everolimus DES. The rate ratio of myocardial infraction is systematically in favor of DES-2s and very often significant. Despite the higher cost of DES-2s, fewer reinterventions can lead to huge savings (i.e., -$479 to -$769 per patient). Moreover, the higher a patient's risk of reintervention, the higher the savings associated with the use of DES-2s. Despite the higher purchase cost of DES-2s compared to BMSs, generalizing their use, in particular for patients at high risk of reintervention, should enable significant savings.