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Risk–Benefit and Cost-effectiveness Analyses of Drug-eluting Stents versus Bare-metal Stents
neutral price of €1,023 at one year and €1,069 at two years. As the Overall, data on the cost-effectiveness of DES use in clinical practice are
actual price of an SES in their institution in 2002 was €1,929, they contrasting. All investigators must be strongly encouraged to analyse
concluded that the unrestricted use of SES is not cost-effective at either their data in light of this, verifying the pertinence of their choices. All of
one and two years, and an additional shrinkage of the DES price must the following data should be taken into account for an ideal analysis:
be strongly encouraged especially as a consequence of new DES
availability with recently acquired CE certification. This increased • number of treated lesions per patient (because every treated lesion
competition together with increased market share of DES could serve to is a potential repeat revascularisation due to restenosis);
reduce the price of DES to that judged cost-effective in the decision • propensity for restenosis for every treated lesion (either lesion-
analytic model. Correspondingly, as the market share of BMS shrinks related or patient-related factors);
their prices will also fall, thus necessitating that the price of DES fall even • propensity for restenosis related to the type of DES (one DES may be
further than predicted. A new scenario is obviously desirable worldwide more effective than another DES) and BMS considered for the
in which a DES will cost less than €900, thus reaching cost-neutrality. comparison (some DES are shown to be more effective than others);
At the same time, since the results of the study of the RESEARCH • number of DES implanted, because the price of the device
registry concern a specific comparison of SES versus BMS, a new- represents a considerable amount of the overall cost;
generation DES or even a new BMS with non-polymeric coating may be • the price of a repeat revascularisation is different if only balloon
responsible for a further reduction in restenosis rates, thus improving angioplasty is performed, or DES implantation or CABG;
the final economic cost. • total cost cannot be reconciled with the reimbursement related to
the DRG; and
Of note, the population studied by Ong showed high-risk features, but • the economic benefit with the use of DES is a function of the
not as high as in the Sicilian registry (e.g. 18% diabetics) or other procedure adopted for the comparison, e.g. PCI with BMS
similar studies
9,12–18
of different real-world settings. Thus, since implantation versus CABG.
the benefit of DES is higher in patients at high risk of restenosis, the
difference in cost-effectiveness of DES versus BMS could be With cost-effective use of DES, physicians can pay attention entirely to
overestimated, urging us to be cautious when we extend these findings technical matters, such as the pertinence of the use of drugs and
out of their context. For example, a statistical analysis of unpublished devices and their clinical efficacy. This may be of great advantage for
data from the Sicilian DES registry
11
with the use of decisional models both patients and healthcare. Pending further information from RCTs,
reached a different result, with evidence of a substantial economic observational studies with DES will continue to supply us with both
benefit of DES, especially in patients who otherwise would be clinical and economic insights, especially when they reflect current
candidates for CABG. practice in interventional cardiology. ■
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