Feature: DES use in stable patients doubles fiscal impact; not so w/ ICDs

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WASHINGTON, D.C.--The costs associated with using drug-eluting stents (DES) has greatly exceeded projected expectations, while the costs associated with using implantable cardioverter-defibrillators (ICDs) is more in line with economic projections. Researchers claim the runaway costs of DES are because the technology is being used in patients in whom there is no proven benefit.

Peter W. Groeneveld, MD, an assistant professor of medicine at University of Pennsylvania and the Philadelphia VA Medical Center, reported the study at the American Heart Association (AHA) Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke meeting last week. Shortly after, Cardiovascular Business News spoke with Groeneveld about his study.

CVB: What was the impetus for undertaking the study?

Groeneveld: While we know from the data that DES and ICDs are among the most common and most costly interventional therapies used in patients with coronary artery disease [CAD] and chronic heart failure [HF], respectively, we didn't know the actual fiscal impact of these technologies. It turns out that from 2003 to 2006, the overall Medicare costs associated with DES were double the projected economic estimates, while those associated with ICDs were not out of line with projections.

CVB: What is the projected cost estimate versus the real-world cost impact of DES?

Groeneveld: One way to figure this out is to guess and say it's the price difference between the new technology versus the old. We found the impact of DES on healthcare costs has been well above what you would expect just based on the price difference.

DES in this population were used in about 500,000 Medicare beneficiaries per year [ages 65-84]. Medicare pays $3,000 more for each procedure using a DES versus bare-metal stent. With a back of the envelope calculation, you'd say that should be about $1.5 billion. We actually find a much higher cost impact. Our current number is $3.3 billion. The reason is when DES were introduced, they changed the way medicine was practiced. Doctors ordered more tests to see if more patients would be candidates for DES and interventionalist started performing more PCIs. And there are various downstream costs because outcomes are different.

CVB: Wouldn't you expect an increased cost impact with new technology?

Groeneveld: You might say this always happens with new technology, but it didn't seem to happen with ICDs. With ICDs, the cost to Medicare is almost completely wrapped up with the cost of the device itself. If you do the same multiplication—what's been the volume of care for new ICDs, the price difference of treating someone with an ICD or not—it winds up being around $750 million. And we found a cost increase of about $774 million. Essentially, for ICDs, there hasn't been as big of a cost impact.

It turns out that there is an amplification effect for some new technologies where the presence of this new therapy means that people start practicing more expensive medicine. In the case of DES, we found that a large proportion of additional costs occurred in patients with relatively stable coronary disease. And that is concerning because there is no really good evidence that people with stable coronary disease should get PCI at all. In some sense, increasing the cost of a procedure, which really shouldn't be done—in patients with really stable coronary disease—is not where medicine should be headed if we're ever going to bend the cost curve. We should go in the opposite direction by trying to reduce costs by reducing unnecessary procedures, not by making unnecessary procedures even more expensive. That's bending the cost curve in the wrong way.

CVB: What is the ratio of DES being used in patients with AMI, non-AMI and stable coronary disease?

Groeneveld: We found that $1.3 billion was spent for patients with AMI, $700 million for patients with non-AMI but acute coronary syndromes and about $1.4 billion for patients with stable coronary disease. That last figure is 58 percent of the cost to Medicare.

CVB: How can your findings be used to possibly enact change in healthcare spending?

Groeneveld: There are a couple of things. Medicare has to take into account more than the price differential when making coverage decisions for new technologies. Also, more than half of the DES that Medicare covered were used off-label. Maybe the next generation of coverage decisions needs to be more circumscribed, much more in line with coverage