Amin Amit P, Spertus John A, Cohen David J, Chhatriwalla Adnan, Kennedy Kevin F, Vilain Katherine, Salisbury Adam C, Venkitachalam Lakshmi, Lai Sue Min, Mauri Laura, Normand Sharon-Lise T, Rumsfeld John S, Messenger John C, Yeh Robert W
Cardiovascular Division, Department of Medicine, Barnes Jewish Hospital, Washington University School of Medicine, St Louis, Missouri, USA.
Arch Intern Med. 2012 Aug 13;172(15):1145-52. doi: 10.1001/archinternmed.2012.3093.
Benefits of drug-eluting stents (DES) in percutaneous coronary intervention (PCI) are greatest in those at the highest risk of target-vessel revascularization (TVR). Drug-eluting stents cost more than bare-metal stents (BMS) and necessitate prolonged dual antiplatelet therapy (DAPT), which increases costs, bleeding risk, and risk of complications if DAPT is prematurely discontinued. Our objective was to assess whether DES are preferentially used in patients with higher predicted TVR risk and to estimate if lower use of DES in low-TVR-risk patients would be more cost-effective than the existing DES use pattern.
We analyzed more than 1.5 million PCI procedures in the National Cardiovascular Data Registry (NCDR) CathPCI registry from 2004 through 2010 and estimated 1-year TVR risk with BMS using a validated model. We examined the association between TVR risk and DES use and the cost-effectiveness of lower DES use in low-TVR-risk patients (50% less DES use among patients with <10% TVR risk) compared with existing DES use.
There was marked variation in physicians' use of DES (range 2%-100%). Use of DES was high across all predicted TVR risk categories (73.9% in TVR risk <10%; 78.0% in TVR risk 10%-20%; and 83.2% in TVR risk >20%), with a modest relationship between TVR risk and DES use (relative risk, 1.005 per 1% increase in TVR risk [95% CI, 1.005-1.006]). Reducing DES use by 50% in low-TVR-risk patients was projected to lower US health care costs by $205 million per year while increasing the overall TVR event rate by 0.5% (95% CI, 0.49%-0.51%) in absolute terms.
Use of DES in the United States varies widely among physicians, with only a modest correlation to patients' risk of restenosis. Less DES use among patients with low risk of restenosis has the potential for significant cost savings for the US health care system while minimally increasing restenosis events.
药物洗脱支架（DES）在经皮冠状动脉介入治疗（PCI）中的益处对于靶血管再血管化（TVR）风险最高的患者最为显著。药物洗脱支架的成本高于裸金属支架（BMS），并且需要延长双联抗血小板治疗（DAPT），如果过早停用DAPT，这会增加成本、出血风险和并发症风险。我们的目标是评估DES是否优先用于预测TVR风险较高的患者，并估计在低TVR风险患者中减少DES使用是否比现有的DES使用模式更具成本效益。
我们分析了2004年至2010年国家心血管数据注册库（NCDR）CathPCI注册库中的150多万例PCI手术，并使用经过验证的模型估计了使用BMS的1年TVR风险。我们研究了TVR风险与DES使用之间的关联，以及与现有DES使用情况相比，在低TVR风险患者中减少DES使用（TVR风险<10%的患者中DES使用减少50%）的成本效益。
医生对DES的使用存在显著差异（范围为2%-100%）。在所有预测的TVR风险类别中，DES的使用率都很高（TVR风险<10%的患者中为73.9%；TVR风险为10%-20%的患者中为78.0%；TVR风险>20%的患者中为83.2%），TVR风险与DES使用之间存在适度的关系（TVR风险每增加1%，相对风险为1.005 [95%CI，1.005-1.006]）。预计在低TVR风险患者中将DES使用减少50%，每年可使美国医疗保健成本降低2.05亿美元，而绝对而言总体TVR事件发生率将增加0.5%（95%CI，0.49%-0.51%）。
在美国，医生对DES的使用差异很大，与患者的再狭窄风险仅有适度的相关性。在再狭窄风险低的患者中减少DES使用有可能为美国医疗保健系统节省大量成本，同时使再狭窄事件的增加幅度最小。
