Cost of stents expected to decrease with time

Study shows stents can benefit patients long term

With new research documenting the long-term benefits of stents, cardiac services managers can expect the cost of these expensive devices to come down over the next few years as usage increases and new designs hit the market.

This could be good news for cardiac administrators who would like to see a decline in the cost of cardiac care patients who need repeat stent procedures.

A recent study at Beth Israel Hospital of Boston shows that stented vessels do well even five years after the devices are implanted. The good news comes when stent use has exploded to nearly half of the 400,000 coronary interventions done each year in the United States. And new types of stents are being reviewed by the U.S. Food and Drug Administration in Washington, DC, for use in the United States.

If new and improved stents enter the market, experts say it could help lower the initial costs of the small cylindrical scaffolds used to prop open narrowed coronary arteries. Implanting stents in a coronary vessel is an accepted treatment in connection with percutaneous transluminal coronary angioplasty and has a lower rate of restenosis than balloon angioplasty.

"Although the stent procedure costs $2,400 more than angioplasty in the hospital, during the first year the reduced need for repeat procedures saves $1,800, so at the end of one year, it’s only $600 more expensive," says Donald S. Baim, MD. Baim, along with Roger J. Laham, MD, and other colleagues at Beth Israel Hospital, studied 175 patients who received stents between June 1988 and April 1991.

Stents stand up to time

Beth Israel was one of the original investigating centers for stents in 1988, when the study began. The study included only patients who had a very localized narrowing of one artery and saphenous vein grafts patients, and it followed them for five years after they received stents. (Stents are being used today for other situations, such as longer narrowings, narrowing of more than one artery, and constructive surgery, but those were not included in the study.) The study was published in the October issue of the Journal of the American College of Cardiology.

"What we were able to prove is that as long as five years after the procedure, the stents provided stability," Laham says. "The long-term outcome of stenting is as excellent as its immediate and acute results, and so this justifies the long-term use of stents."

Baim says the clinical benefit of using stents is that the devices "buy additional quality-adjusted life years at a reasonable cost-effectiveness ratio."

Some hospitals that have been using stents since 1994, when the device was approved for use in the United States, have found ways to reduce costs, primarily through changing the anti-clotting medications used with them, experts say. (See related article on medications that reduce length of stay, p. 5.)

"Doctors are trained to be more aggressive and go with different approaches than they did initially, so we have better outcomes and shorter hospital stays," says Mark Scott, director of the cardiac catheterization lab at Columbia (SC) Providence Heart Institute. Providence has South Carolina’s largest cardiac program, doing 5,000 invasive procedures and about 1,000 open heart surgeries annually.

Competition will drive down cost

Scott says he hopes stent prices will drop from their current prices of up to $1,600 per stent once new products enter the market.

"There are at least four other stents that will be brought to the market here shortly," Scott predicts. "More than a dozen are being proven in Europe and the Middle East."

Beth Israel Hospital has been testing different stents, and Laham says the devices are improving. "The stent design is going to be much better, and the delivery technique is going to be much better," he comments.

The only two stents available in the United States now are designs from the mid-1980s, Baim says.

"There are now 20 or more second-generation designs that are easier to place and may have better results, and these stents are undergoing testing now," he adds.

Once these are on the market, Baim says, the costs probably will go down, just as they did for angioplasty balloons, which initially cost $600 each and now cost $300 each.

Laham recalls that before Beth Israel Hospital’s long-term study, the cardiac care community had concerns about implanting stents for long periods of time. The study, however, should allay those fears because it showed a six-month restenosis rate of 26.1%. The patients who received stents underwent angioplasty or bypass surgery to reopen the vessel at a rate of 19.8% after five years. After one year, that rate was 14.4%.

These compare to a restenosis rate after angioplasty of about 40% in six months, Baim says.

"It turned out all the stented vessel problems occurred within the first year in both native-coronary and venous-bypass-graft patients," Baim explains.

The study showed patients had an overall revascularization procedure rate of 41.2% after five years. But Baim said those procedures were performed at sites other than where the stents had been placed.

"There was essentially no further misbehavior between the stented vessel in one year and four to six years. All the late procedures were caused by progression of coronary disease at other sites," Baim adds.

Many physicians and hospitals probably will increase stent use now that the device’s stability has been proven, experts say.

"I see that the future for stenting is very good," remarks Tamme Hafer, MS, RN, administrative director of cardiac and emergency services for Kettering (OH) Medical Center. Kettering does about 2,000 cardiac catheterizations and 750 open-heart surgeries annually.

"I expect our use of stents will continue to go up," Hafer says.

Besides the high cost, the major drawback to stent use has been that they are limited to use on larger vessels, Laham and Baim point out.

"We’re staying away from vessels smaller than 2.5 millimeters in diameter, and we try to avoid stenting in very long segments of vessel," Baim explains.