Circulation, Vol 89, 1859-1874, Copyright © 1994 by American Heart Association
DJ Cohen, JA Breall, KK Ho, RE Kuntz, L Goldman, DS Baim and MC Weinstein
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.
ARTICLES
Evaluating the potential cost-effectiveness of stenting as a treatment for symptomatic single-vessel coronary disease. Use of a decision- analytic model
Charles A. Dana Research Institute, Boston, MA.
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