Incremental cost-effectiveness of 2 drug-eluting stents compared to a new generation bare-metal stent in a ‘real-world’ setting

Repeat interventions to treat restenosis are the Achilles heal of stenting. The new drug-eluting stents (DES) have reduced the need for repeat interventions significantly compared to bare-metal stents (BMS), however, they are so much more expensive, that their use in all patients threatens to ‘kill’ hospital budgets. This has led to difficult discussions among physicians, patients and hospital administrators with regard to who should or could get DES and it was questioned whether withholding DES for cost reasons would not be rationing.

The prospective, randomised, controlled Basel stent cost effectiveness trial (BAsel Stent Kosten Effektivitäts Trial, BASKET) answers these questions for the first time based on 826 consecutive patients treated with PCI and stenting at the University Hospital of Basel, Switzerland. Results presented in Stockholm will show whether DES are worth their price in all patients or whether at least certain patient groups can be identified in which they are cost-effective.

All patients treated with PCI and stenting over a one year period were randomised to receive a DES or a BMS irrespective of indication and risk for restenosis. Three fifths of patients presented with acute infarction or unstable coronary disease and more than two thirds had multivessel disease, not different between the three groups. Patients were treated with nearly two stents each for a total stent length of more than 30 mm per patient.

All patients were followed for 6 months for occurrence of death, non-fatal infarction and target vessel revascularization as well as for cost (baseline, stent and follow-up costs). Results will be presented as difference in costs between DES and BMS in relation to difference in major cardiac events between the two stent types and among the two DES tested. Subgroup analyses will indicate whether this incremental cost-effectiveness ratio is different in certain high risk subgroups such as patients with multivessel disease, small treated vessels, diabetes, long treated segments or those treated in acute coronary syndromes compared with low risk patients.

These findings may have an important impact on the use of DES in daily practice in view of their high cost and also on preferences for one of the two DES. This is particularly true since BASKET was performed entirely independently from the device industry, a reason why the eagerly awaited detailed results can only be revealed in Stockholm.