Invited Commentary
Aug 13/27, 2012

How Drug-Eluting Stents Illustrate Our Health System's Flawed Relationship With TechnologyComment on “Use of Drug-Eluting Stents as a Function of Predicted Benefit”

Author Affiliations

Author Affiliations: Department of Veterans Affairs, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia.

Arch Intern Med. 2012;172(15):1152-1153. doi:10.1001/archinternmed.2012.2724

New medical technologies are the primary drivers of rising health care costs,1 but the US health care system has generally performed poorly in incorporating new drugs, devices, imaging techniques, and invasive procedures in a manner that maximizes the value—defined as health benefits relative to costs—delivered to patients while simultaneously restraining the use of such technologies in settings where they predictably provide little or no value. This tendency was clearly evident in the analysis by Amin et al2 of nationwide catheterization laboratory registry data. This study demonstrated the consistently high likelihood that US percutaneous coronary intervention (PCI) patients in 2004 through 2010 received a drug-eluting stent (DES), regardless of the presence of clinical predictors that suggested a low pretreatment risk of subsequent target-vessel revascularization (TVR), and TVR risk reduction is the only evidence-based benefit delivered by DES. In fact, 74% of such low-TVR-risk patients received a DES rather than a less costly bare metal stent (BMS)—arguably many of these were missed opportunities to maximize health care value. The authors further postulate that eliminating DES use among low-TVR-risk patients would save $400 million annually, at a cost of fewer than 1000 additional TVR cases per year. As TVR typically has only modest impact on patients' quality of life and negligible impact on lifespan, it is reasonable to conclude that such an economic tradeoff should be a societal “no brainer.”