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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.”

By way of comparison, the British do things differently. The United Kingdom's National Institute for Health and Clinical Excellence (NICE)3 recommends a DES for PCI only if the target artery is smaller than 3 mm in diameter or if the lesion is longer than 15 mm, and if the DES-BMS unit price difference is “no more than £300” (ie, approximately $480). While NICE guidance publications on medical devices do not compel British physicians and hospitals to comply, recent estimates of DES use rates among patients with acute coronary syndrome in the United Kingdom revealed that only 47% of PCI patients received a DES in 2007,4 while US rates approached 70% in the same year.5 There is little evidence to suggest that British patients with coronary artery disease were treated suboptimally by their physicians, but it is likely that on average they were treated more inexpensively.

In the absence of either clinical evidence or guidelines suggesting that the DES is clearly superior to the BMS outside of highly specific clinical settings, why do American physicians continue to use the DES so indiscriminately? The answer is undoubtedly a combination of many factors. Some physicians may be convinced that the superiority of the DES to BMS goes beyond the enrollment criteria of clinical trials and essentially includes every scenario in which the DES is not absolutely contraindicated. The argument would be that the absence of evidence (of a clinical benefit) is not necessarily evidence of absence, and thus an extrapolation of DES effectiveness to settings outside of the published evidence base is not unreasonable. In fact, the willingness of clinicians to engage in such “off-label” use of drug-eluting stents has been well-documented.6

However, it is unlikely that pure “scientific agnosticism” about the relative benefits of the DES vs BMS entirely explains persistent and widespread clinician enthusiasm. While there is limited empirical evidence directly relevant to the DES vs BMS decision, decision theory suggests that some clinicians may favor a particular treatment option after a prior adverse experience with the alternative, while other physicians may choose a DES in anticipation of future regret and/or concerns about future accusations of malpractice, were a patient who received a BMS to have a subsequent coronary event. There is also the undeniable appeal of new technology for its own sake: some physicians may value assuring their patients that the most cutting-edge technology was used in their care, or conversely physicians may be reluctant to tell their patients that an older, “less sophisticated” technology was selected for their treatment. Finally, no interventional cardiologist is an island; the practice patterns of clinical peers undoubtedly shape physician behavior,7 as inevitably do the practice patterns of training programs that produce new interventional cardiologists.

Further explanations for the enduring popularity of the DES can be found in the dynamics of the health care marketplace. The influence of medical device manufacturers in their advertising efforts, involvement at national conferences, and detailing of clinicians in their hospitals and catheterization laboratories is impossible to quantify, yet it is likewise difficult to dismiss these highly organized marketing efforts as ineffectual. The local supply (and selection) of various stents in a physician's catheterization laboratory and hospital may also play a role in the DES-BMS choice. Most importantly, few interventional cardiologists or their patients face financial incentives at the point of care encouraging a choice of stent that maximizes economic value. In a “price-free” environment, the natural inclination is to select the more expensive option.8

As the resources to pay for health care are limited, it is inevitable that medical decision making in the US will be increasingly driven by value maximization. Presumably this will be accomplished to some degree by placing local health systems (eg, Accountable Care Organizations) and their constituent hospitals and physicians increasingly at risk for the economic consequences of their decision making. It is also likely that patients will increasingly face different financial consequences depending on the value of the technologies they receive, thus motivating them to engage in value-oriented discussions with their physicians in advance of treatment. Nevertheless, the distance from the current, volume-based, technology-avid health care system to a future value-maximizing system is not trivial. The use pattern of DES during the past 9 years illustrates how far away the system is from consistently embracing value-based medical decision making, and it also enumerates the many barriers and inertial practices in US health care that must be surmounted to reach economic sustainability.

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Article Information

Correspondence: Dr Groeneveld, Department of Medicine, University of Pennsylvania School of Medicine, 1229 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104 (petergro@upenn.edu).

Published Online: July 9, 2012. doi:10.1001/archinternmed.2012.2724

Financial Disclosure: None reported.

Disclaimer: The views expressed in this article are the author's and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

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