TECHNOLOGY: Dump the stent, have a by-pass

You may recall that when I wrote about the market for drug-coated stents, I made an off-hand remark about a Canadian health services researcher who told me that stents were a waste of money because, from a health services research point of view, you get more bang for your buck by just doing angio. Well it appears that some health services researchers–who are even smarter than the Canadians, because they’re at Stanford–have gone even further and concluded that drug-coated stent or not, bypass surgery is more cost-effective than angio! (Full disclosure: I went through the Stanford HSR program & I studied under/with three of the report’s authors. I don’t know anything about this research, but I do know that they are a hell of a lot smarter than I am).

The researchers built a complex computer model based on a study done 10 years ago comparing angioplasty with cardiac bypasss surgery. They built in corrections that made the data look as though today’s rate of stent use was used at that time, and adjusted for the improved impact of today’s stents.  They then looked at the outcomes and costs of follow-up treatment over the next five years. It turns out  that the five year cost was about the same and that quality of life was actually better for those who’d had the bypass.  In fact the advantages by the ten year mark were considerable.  Here’s a detailed press release explaining the study’s methods and conclusions.

Even more direct is what the authors say in the abstract:

    "Primary stent use cost an additional $189,000 per QALY* gained compared with a strategy that reserved stent use for treatment of suboptimal balloon angioplasty results" and they conclude that "Bypass surgery results in better outcomes than angioplasty in patients with multivessel disease, and at a lower cost".

Traditionally in this country, we’ve ignored health services research as it often tells us that less care is better care, but less care means less money to those in the industry and those supplying it. Here’s a case where something that costs a little more up-front and has its own constituency (bypass surgery) saves money and improves outcomes over the long-run compared to its more recently developed rival. If this was paid for by insurance companies that expected their members to be in another plan within two years, they’d be right to go for the cheaper option.  But in this case the majority of people undergoing these procedures are in one insurance plan called Medicare, paid for by you and me. And if they’re not in Medicare when they undergo the procedure, they will be soon enough when the added costs from recurring blockages that follow angio often require another procedure. So it’s not unreasonable to expect that the folks at CMS are reading this study too and may start taking a long look the use of stents. Prepare for this study to be widely ignored by the stent industry who right now I’m sure are working on their own research to refute it. $5 billion will not go quietly into the night.

*QALY is Quality Adjusted Life Year–a measure of life expectancy that takes into account the patient’s health, so that a year lived in good health is valued more highly than one lived with serious health conditions restricting activities of daily living or requiring significant medical care.

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