Abstract 14469: Optimal Use of Drug-Eluting Stents in PCI: Implications of Healthcare Policy in Real-World Practice
Background: To ensure efficient utilization of resources, several health organizations have outlined explicit criteria for drug-eluting stent (DES) use in percutaneous coronary intervention (PCI). The potential impact of these policies on DES use, and the correlation with DES-related benefit (absolute reduction in target vessel revascularization [TVR]), have not been described.
Methods: We used data from the EVENT Registry to examine patients’ eligibility for DES use according to 3 published policies (Washington State [US], National Institute of Clinical Excellence [UK], and Ontario [CAN]) and select thresholds of predicted 1-yr risk of TVR with bare metal stents (estimated using MassDAC NCDR model) among 10,144 unselected PCI patients from 55 US centers. For each policy and predicted TVR risk threshold, we compared the mean absolute risk reduction (ARR) in TVR risk, expected with DES vs. bare metal stents, and the number needed to treat (NNT) to avoid 1 TVR between patients who did vs. did not meet the criteria for DES use.
Results: Overall, 86% of patients in the EVENT Registry received at least 1 DES. The expected ‘optimal’ rate of DES use, using a policy-based approach, however, varied dramatically from 21% (Ontario criteria) to 97% (Washington State criteria) with similar, modest difference in mean NNT by DES-eligibility status; range in mean NNT across polices was 6 to 10 (Table). In contrast, use of individualized estimates of 1-yr TVR risk yielded greater differences in mean NNT and ranged from 32 patients (using >5% TVR risk threshold to treat with DES) to 12 patients (using >15% TVR risk threshold to treat with DES).
Conclusion: Among unselected patients undergoing PCI in the US, policies based on explicit indications for DES use can identify patients with greater potential to benefit from these stents, but less so than an individualized risk-based approach. Policies should reflect both the proportion of desired DES use and the magnitude of desired TVR reduction.
- © 2011 by American Heart Association, Inc.