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Defining patients at high risk for gastrointestinal hemorrhage after drug-eluting stent placement: a cost utility
Neil Gupta1, Rahul Nayak, Scott W Grisolano
1Division of Gastroenterology/Hepatology, University of Kansas Medical Center, Kansas City, KS 66160, USA. ngupta@kumc.edu
Insights
Drug-eluting stents (DES) are cost-effective for most patients needing coronary artery procedures. However, those with higher gastrointestinal bleeding risks may not benefit from DES due to prolonged dual anti-platelet therapy.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Drug-eluting stents (DES) reduce repeat coronary revascularization but necessitate dual anti-platelet therapy (DAT).
- Prolonged DAT increases the risk of gastrointestinal (GI) bleeding.
- Previous studies suggest DES are cost-effective for average GI bleeding risk patients.
Purpose of the Study:
- To evaluate the cost-effectiveness of DES versus bare metal stents (BMS).
- To assess the impact of gastrointestinal (GI) bleeding risk on DES cost-effectiveness.
- To determine the threshold for GI bleeding risk at which DES may not be the optimal strategy.
Main Methods:
- A Markov model was employed to compare DES and BMS.
- A hypothetical cohort of 60-year-old individuals requiring percutaneous coronary intervention (PCI) was simulated.
- Primary outcomes focused on the incremental risk of GI bleeding from DAT relative to willingness to pay (WTP) thresholds ($50k, $100k, $150k per QALY).
Main Results:
- For a WTP of $100,000/QALY, DES remains cost-effective even with a 10.8-fold increased risk of GI bleeding from DAT.
- In patients with two GI bleeding risk factors, the threshold relative risk of GI bleeding from DAT drops significantly to 1.6.
Conclusions:
- Substantial GI bleeding risk from DAT does not preclude DES cost-effectiveness in average-risk patients.
- DES are unlikely to be cost-effective for patients with two or more risk factors for GI bleeding.
Introduction:
The study goal was to evaluate the cost-effectiveness of drug-eluting stent (DES) placement with consideration of gastrointestinal (GI) bleeding risk. DES reduce the need for future coronary revascularization, but require prolonged dual anti-platelet (DAT) therapy, which may increase the risk for GI bleeding. While DES have been found to be cost-effective in patients at average risk for GI bleeding, they may not be the most cost-effective strategy in higher risk patients.
Methods:
A Markov model was created to compare DES with bare metal stents (BMS). Patients were a hypothetical cohort of 60-year-old individuals with coronary artery stenosis that required nonemergent percutaneous coronary revascularization (PCI). The primary outcomes were the threshold incremental risks of GI bleeding from DAT based on willingness to pay (WTP) of $50,000, $100,000, and $150,000 per quality adjusted life year (QALY) gained.
Results:
For a WTP of $100,000, the relative risk of GI bleeding from DAT could be as high as 10.8 (when compared to aspirin alone) before DES would no longer be cost-effective. In patients with two risk factors for GI bleeding, the threshold relative risk could be as low as 1.6.
Conclusion:
In average-risk patients, the risk of GI bleeding from DAT can be substantial without affecting the cost-effectiveness of DES. However, DES are unlikely to be cost-effective in patients with two or more risk factors for GI bleeding.
