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Evaluating the potential cost-effectiveness of stenting as a treatment for symptomatic single-vessel coronary
D J Cohen1, J A Breall, K K Ho
1Charles A. Dana Research Institute, Boston, MA.
Insights
Coronary stenting offers better outcomes than balloon angioplasty for single-vessel disease, with a cost-effectiveness ratio similar to other accepted treatments. Primary stenting is recommended over secondary stenting for improved results and cost-effectiveness.
Area of Science:
- Cardiovascular Medicine
- Health Economics
- Interventional Cardiology
Background:
- Coronary stenting shows improved immediate results and lower restenosis rates compared to balloon angioplasty.
- However, coronary stenting involves significantly higher hospital costs.
- This study evaluates the cost-effectiveness of Palmaz-Schatz coronary stenting versus conventional balloon angioplasty for symptomatic single-vessel coronary disease.
Purpose of the Study:
- To assess the potential cost-effectiveness of Palmaz-Schatz stenting (PSS) compared to conventional angioplasty (PTCA).
- To model quality-adjusted life expectancy and lifetime treatment costs for patients with single-vessel coronary disease.
Main Methods:
- A decision-analytic model was developed to compare PSS and PTCA.
- Literature review (up to September 1993) provided probabilities for procedural success, abrupt closure, and restenosis.
- Procedural costs were based on actual economic costs at Beth Israel Hospital.
Main Results:
- Coronary stenting was estimated to yield higher quality-adjusted life expectancy but at an increased cost.
- The incremental cost-effectiveness ratio for stenting was $23,600 per quality-adjusted life year gained.
- Primary stenting was found to be more effective and cost-effective than secondary stenting.
Conclusions:
- Decision-analytic modeling is valuable for evaluating new coronary interventions.
- Elective coronary stenting may be a reasonably cost-effective treatment for selected single-vessel disease patients.
- Primary stenting's cost-effectiveness is sensitive to restenosis rates and costs; further studies are needed for specific subsets.
Background:
Coronary stenting appears to provide more predictable immediate results and lower rates of restenosis than conventional balloon angioplasty for selected lesion types, but its hospital costs are significantly higher. This study was designed to evaluate the potential cost-effectiveness of Palmaz-Schatz coronary stenting relative to conventional balloon angioplasty for the treatment of patients with symptomatic, single-vessel coronary disease.
Methods And Results:
We developed a decision-analytic model to predict quality-adjusted life expectancy and lifetime treatment costs for patients with symptomatic, single-vessel coronary disease treated by either Palmaz-Schatz stenting (PSS) or conventional angioplasty (PTCA). Estimates of the probabilities of overall procedural success (PTCA, 97%; PSS, 98%), abrupt closure requiring emergency bypass surgery (PTCA, 1.0%; PSS, 0.6%), and angiographic restenosis (PTCA, 37%; PSS, 20%) were derived from review of the literature published as of September 1993. Procedural costs were based on the true economic (ie, variable) costs of each procedure at Boston's Beth Israel Hospital. On the basis of these data, coronary stenting was estimated to result in a higher quality-adjusted life expectancy than conventional angioplasty but to incur additional costs as well. Compared with conventional angioplasty, stenting had an estimated incremental cost-effectiveness ratio of $23,600 per quality-adjusted life year gained. Although the cost-effectiveness ratio for stenting changed with variations in assumptions about the relative costs and restenosis rates, it remained less than $40,000 per quality-adjusted year of life gained--and thus was similar to many other accepted medical treatments--unless the stent angiographic restenosis rate was > 23%, the angioplasty restenosis rate was < 34%, or the cost of stenting (including vascular complications) exceeded that of conventional angioplasty by more than $3000. The alternative strategy of secondary stenting (initial angioplasty followed by stenting only for symptomatic restenosis) was estimated to be both less effective and less cost-effective than primary stenting over a wide range of plausible assumptions and thus does not appear to be cost-effective when primary stenting is also an option.
Conclusions:
Decision-analytic modeling can be used to evaluate the potential cost-effectiveness of new coronary interventions. Our analysis suggests that despite its higher cost, elective coronary stenting may be a reasonably cost-effective treatment for selected patients with single-vessel coronary disease. Primary stenting is unlikely to be cost-effective for lesions with a low probability of restenosis (eg, < 30%) or for patients for whom the cost of stenting is expected to be much higher than usual (eg, because of a high risk of vascular complications). Given the sensitivity of the cost-effectiveness ratios to even modest variations in the relative restenosis rates and cost estimates, future studies will be necessary to determine more precisely the cost-effectiveness of coronary stenting for specific patient and lesion subsets.