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From the Departments of Community Health Sciences (Shrive, Manns, Galbraith, Ghali) and Medicine (Manns, Knudtson, Ghali), the Centre for Health and Policy Studies (Shrive, Manns, Galbraith, Ghali) and the Division of Cardiology (Knudtson), University of Calgary, Calgary, Alta., Merril Knudtson is the principal investigator of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH).
Correspondence to: Dr. William A. Ghali, Rm. HSG239, 3330 Hospital Dr. NW, Calgary AB T2N 4N1; fax 403 210-3818; wghali{at}ucalgary.ca
Background: Sirolimus-eluting stents have recently been shown to reduce the risk of restenosis among patients who undergo percutaneous coronary intervention (PCI). Given that sirolimus-eluting stents cost about 4 times as much as conventional stents, and considering the volume of PCI procedures, the decision to use sirolimus-eluting stents has large economic implications.
Methods: We performed an economic evaluation comparing treatment with sirolimus-eluting and conventional stents in patients undergoing PCI and in subgroups based on age and diabetes mellitus status. The probabilities of transition between clinical states and estimates of resource use and health-related quality of life were derived from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Information on effectiveness was based on a meta-analysis of randomized controlled clinical trials (RCTs) comparing sirolimus-eluting and conventional stents.
Results: Cost per quality-adjusted life year (QALY) gained in the baseline analysis was Can$58 721. Sirolimus-eluting stents were more cost-effective in patients with diabetes and in those over 75 years of age, the costs per QALY gained being $44 135 and $40 129, respectively. The results were sensitive to plausible variations in the cost of stents, the estimate of the effectiveness of sirolimus-eluting stents and the assumption that sirolimus-eluting stents would prevent the need for cardiac catheterizations in the subsequent year when no revascularization procedure was performed to treat restenosis.
Interpretation: The use of sirolimus-eluting stents is associated with a cost per QALY that is similar to or higher than that of other accepted medical forms of therapy and is associated with a significant incremental cost. Sirolimus-eluting stents are more economically attractive for patients who are at higher risk of restenosis or at a high risk of death if a second revascularization procedure were to be required.
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