1. DES Economics:
Insights for 2010 and Beyond
David J. Cohen, M.D., M.Sc.
Director of Cardiovascular Research
Saint Luke’s Mid America Heart Institute
Professor of Medicine
University of Missouri-Kansas City

2. DISCLOSURES
David J. Cohen, MD
Consulting Fees
– Medtronic CardioVascular, Inc., Cordis, a
Johnson & Johnson company
Grants/Contracted Research
– Abbott Vascular, Boston Scientific
Corporation, Daiichi Sankyo, Inc. and Eli Lilly
and Company, Edwards Lifesciences LLC

3. Cost-Effectiveness of Drug-Eluting Stents
•• DES vs. BMS comparisons
DES vs. BMS comparisons
– Results based on early randomized trials
– Results based on early randomized trials
•• Impact of recent practice changes
Impact of recent practice changes
•• Impact of stent thrombosis and clopidogrel
Impact of stent thrombosis and clopidogrel
duration
duration

4. Cost-Effectiveness of Drug-Eluting Stents
•• DES vs. BMS comparisons
DES vs. BMS comparisons
– Results based on early randomized trials
– Results based on early randomized trials
•• Impact of recent practice changes
Impact of recent practice changes
•• Impact of stent thrombosis and clopidogrel
Impact of stent thrombosis and clopidogrel
duration
duration

5. SIRIUS
1-Year Medical Care Costs
∆ = +$309 (p=0.64)
∆
$20,000
$16,813 + 9737
$16,504 + 11,511
$15,000
$5,468 Follow-up
$8,040
Initial Hospitalization
$10,000
C/E ratio ::
C/E ratio
$1650 per repeat
$1650 per repeat
$11,345
$5,000 revasc avoided
revasc avoided
$8,464
$27,000 per
$27,000 per
$0 QALY gained
QALY gained
Sirolimus Control

6. Cost-Effectiveness of DES in 2003:
Impact of Bare Metal Stent TVR Rate
Healthcare system perspective
$25,000
2003 Model Assumptions
Cost per repeat revasc avoided
• TVR risk reduction 75%
$20,000
• Incremental DES cost =
$2000/stent
$15,000
• 1.4 stents/pt
$10,000
Conclusions
Conclusions
$5,000 •• DES reasonably cost-
DES reasonably cost-
effective if bare stent
effective if bare stent
TVR rate > 14%
TVR rate > 14%
$0
5% 10% 15% 20% 25%
TVR rate with bare stent

7. Cost-Effectiveness of Drug-Eluting Stents
•• DES vs. BMS comparisons
DES vs. BMS comparisons
– Results based on early randomized trials
– Results based on early randomized trials
•• Impact of recent practice changes
Impact of recent practice changes
•• Impact of stent thrombosis and clopidogrel
Impact of stent thrombosis and clopidogrel
duration
duration

8. DES Economics
Changes in Practice and Outcomes:
2010 vs. 2003
2003 2009
Cost Difference $2000/stent $1000/stent
Stents/case 1.4 1.6
Clopidogrel duration 3 months 12+ months
TVR relative risk 75% (early RCTs 50% (Kirtane meta-
reduction with angio f/u) analysis)

9. Cost-Effectiveness of Drug-Eluting Stents:
2009 vs. 2003
US Healthcare system perspective
$25,000 New Assumptions
• Incremental cost per
Cost per repeat revasc avoided
DES = $1000
$20,000
• DES per case = 1.6
$15,000 • 50% reduction in TVR
with DES vs. BMS
$10,000 • 12 months of clopidogrel
for all DES
$5,000 Implications
Implications
•• DES reasonably cost-
DES reasonably cost-
$0 effective if bare stent
effective if bare stent
5% 10% 15% 20% 25% TVR rate > 11%
TVR rate > 11%
TVR rate with BMS

10. Cost-Effectiveness of Drug-Eluting Stents
•• DES vs. BMS comparisons
DES vs. BMS comparisons
– Results based on early randomized trials
– Results based on early randomized trials
•• Impact of recent practice changes
Impact of recent practice changes
•• Impact of stent thrombosis and clopidogrel
Impact of stent thrombosis and clopidogrel
duration
duration

11. Relative Impact of Restenosis and Mortality on
Quality-Adjusted Life Expectancy
10 8.2
Reduction in 8
Quality-
Adjusted Life 6 125x
Expectancy
(per event) 4
2 0.07
0
Restenosis Death
Cohen DJ et al. Circulation 2001

12. Impact of VLST on
Quality-Adjusted Sensitivity Analysis on
Life Expectancy
Additional Risk of Stent Thrombosis in DES
12.12
DES
BMS
Threshold Values:
12.12 Add_Increased_Risk_of_ST_in_DES = 0.0021
EV = 12.11
12.11
Expected Value (QALY)
QALYs
12.11
Implication:
12.10
DES preferred over only if
excess LST < 0.2 %/yr
12.10
12.09
0.0000 0.0010 0.0020 0.0030 0.0040 0.0050
Excess Additional Risk of Stent Thrombosis in DES (per year)
Risk of Late Stent Thrombosis
Garg P et al. J Am Coll Cardiol 2008;51:1844-53

13. Impact of VLST Risk Duration
0.45
0.40
Incremental Risk of VLST (% per year)
0.35
0.30
0.25
0.20
0.15
0.10
0.05
0.00
2 3 4 5 6 7 8 9 10
Duration of Excess Thrombosis Risk (Years after Initial PCI)
Garg P et al. J Am Coll Cardiol 2008;51:1844-53

14. Cost-Effectiveness of DES
Impact of a Thromboresistant Stent
Cost-Effectiveness ($/QALY)
$100,000 Model Assumptions
∆ cost = $400/stent • Background ST rate (early +
$75,000 late + very late) = 1.5%
• ST cost = $17,000/event
(Reynolds et al, 2002)
$50,000
Implications
Implications
$25,000 •• Even at a cost premium of
Even at a cost premium of
$400/stent, a thrombo-
$400/stent, a thrombo-
resistant DES would be
resistant DES would be
$0 reasonably cost-effective if
reasonably cost-effective if
0% 25% 50% 75% 100% reduced total ST by 25%
reduced total ST by 25%
ST Relative Risk Reduction

15. Cost-Effectiveness of DES
Impact of Clopidogrel Duration
Cost per Repeat
Revascularization Avoided
$20,000 Take Home Message Assumptions
• DES to
• As restenosis rates have continued cost = $2000/stent
$15,000
decline, reductions in stent thrombosisreduction = 70%
• TVR risk
and clopidogrel duration are now more rate =14%
• BMS TVR
$10,000 attractive targets for improved• DES of clopidogrel
1 month
design than further reductions in BMS
after
$5,000
restenosis • No benefit of clopidogrel
other than prevention of
stent thrombosis
$0
0 6 12 18 24 30 36
Clopidogrel Duration

16. CHARISMA: Established Disease Subgroup
Cost-Effectiveness Results
Clopidogrel + ASA Difference
ASA alone (95% CI)
Cost in trial $13,502 $10,386 $3116
0.01
Life-years in trial 2.58 yrs 2.57 yrs
(-0.01, 0.02)
-0.07
Total life-years lost * 0.62 yrs 0.69 yrs
(-0.16, 0.01)
Incremental Cost-Effectiveness Ratio
∆C/∆E = $38,705/life-year gained
Chen J et al. Value in Health 2009

17. Summary
• Despite substantial changes in practice patterns over
the past 6 years, most of the fundamental insights
regarding the cost-effectiveness of drug-eluting stents
have changed very little
– DES are cost-saving for only a minority of the PCI population
– Nonetheless, DES appear reasonably cost-effective compared
with BMS for a substantial fraction of PCI patients (predicted
BMS TVR > 10-11%)
• Given current clinical data, the most promising targets
for improving the cost-effectiveness of DES relate to
reductions in stent thrombosis or mandatory DAPT
duration