CMAJ • May 22, 2007; 176 (11). doi:10.1503/cmaj.1070021.
© 2007 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

Drug-eluting stents

Stéphane Rinfret* and Erick Schampaert{dagger}

Interventional Cardiology and Health Economics Research, Centre Hospitalier de l'Université de Montréal, Montréal, Que.;* Interventional Cardiology, Hôpital du Sacré-Coeur, Université de Montréal, Montréal, Que.{dagger}

The results of the cost-effectiveness study by Suzanne Ligthart and associates1 bring into question the independence and validity of the science generated by health services researchers working with industry support, even in cases in which the support is unrestricted and the research is performed without any direct input from the funder. We suggest that important biases might have affected the authors' conclusions.

It is possible that the quality rating of the studies was biased by knowledge of the studies' conclusions and funding source. Indeed, it is surprising that some cost-effectiveness studies published in high-impact journals, especially the one by Cohen and colleagues,2 were rated poorly by the reviewers. In addition, researchers may have undisclosed relationships with the government agencies that support some of their cost-effectiveness research. Interestingly, most of the highly rated cost-effectiveness analyses were requested and financed by health technology assessment agencies, whose mandate is to provide policy guidance to third-party payers. We believe such funding may influence studies' conclusions about cost-effectiveness, given that researchers are expected to provide responsible policy statements in the name of the health technology agency. Therefore, an alternative conclusion to that proposed by Ligthart and associates could be that publicly funded studies of the cost-effectiveness of drug-eluting stents are not likely to encourage widespread adoption of this technology unless it is expected to save costs. Finally, other factors such as geographic variation in the pricing of drug-eluting stents and repeat procedure costs (which are very different in the United States and Canada) or variations in the baseline risk of clinical restenosis in the population of interest may have had at least as much impact on the studies' conclusions as the source of funding.

In a 2006 industry-sponsored study3 based on the results of the C-SIRIUS trial,4 which was not included in the study by Ligthart and colleagues, we concluded that the cost-effectiveness of drug-eluting stents was borderline in high-risk patients. We clearly stated that drug-eluting stents would only be cost-effective in Canada in patients with a 12% or higher risk of repeat procedures. This is a clear example of responsible and unbiased conclusions reached by independent researchers who work with various sources of funding, including the medical device industry.

Footnotes

Competing interests: Stéphane Rinfret and Erick Schampaert receive funding from the medical device industry for their research.


REFERENCES

  1. Ligthart S, Vlemmix F, Dendukuri N, et al. The cost-effectiveness of drug-eluting stents: a systematic review. CMAJ 2007;176(2):199-205.[Abstract/Free Full Text]
  2. Cohen DJ, Bakhai A, Shi C, et al. Cost-effectiveness of sirolimus-eluting stents for treatment of complex coronary stenoses: results from the Sirolimus-Eluting Balloon Expandable Stent in the Treatment of Patients With De Novo Native Coronary Artery Lesions (SIRIUS) trial. Circulation 2004;110:508-14.[Abstract/Free Full Text]
  3. Rinfret S, Cohen DJ, Tahami Monfared AA, et al. Cost effectiveness of the sirolimus-eluting stent in high-risk patients in Canada: an analysis from the C-SIRIUS trial. Am J Cardiovasc Drugs 2006;6(3):159-68.[CrossRef][Medline]
  4. Schampaert E, Cohen EA, Schluter M, et al. The Canadian study of the sirolimus eluting stent in the treatment of patients with long de novo lesions in small native coronary arteries (C-SIRIUS). J Am Coll Cardiol 2004;43:1110-5.[Abstract/Free Full Text]




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