COST EFFECTIVENESS OF DRUG ELUTING STENTS IN THE PERCUTANEOUS TREATMENT OF STABLE CORONARY ARTERY DISEASE IN BRAZIL

Purpose: Although Drug Eluting Stents (DES) have been widely incorporate into clinical practice in development countries, several countries restrict their broadly use mainly based on their high cost and unfavorable incremental cost-effectiveness ratios (ICER). This study aims to evaluate the ICER of DES as an alternative to bare metal stents (BMS), in the Brazilian public health system (SUS) scenario, for treatment of coronary artery disease (CAD), considering updated effectiveness and costs of commercially available stents.

Method: An analytic Markov model was built to simulate short-term (within 1 year) and long-term (lifetime) outcomes and costs after a percutaneous procedure with BMS or one of the following: sirulimus(SES), paclitaxel(PES), everolimus(EES) or zotarolimus(ZES). It was considered a cohort of patients with symptomatic, single-vessel CAD that could undergo any of the five strategies. Model parameters were extracted from the medical literature and cost data were based on SUS reimbursement list. A CAD patient’s cohort in tertiary hospital was retrieved for outpatients’ costs and utilities. Primary endpoints were ICER for 1-year target vessel revascularization (TVR) avoided and quality-adjusted life-year (QALY) gained.  Economic values of one GDP/capita (US$11,875) for TVR avoided and three GDP/capita for QALY were used as willingness-to-pay thresholds.

Results: Main base-case and SA results are reported in table 1. In the probabilistic SA there was a 14% probability of EES being a cost-effective strategy.

Conclusion: As valued in the Brazilian market, DES is not a good value for money for QALY and for TVR avoided in comparison with BMS. DES should cost less than twice of BMS price, in order to be a cost-effective alternative.

Table 1.
		x1,000 US$/QALY gained				x1,000 US$/TVR avoided
		SES	PES	EES	ZES	SES	PES	EES	ZES
Base Case		109	222	70	dominated	22	34	22	34
Sensitivity Analisys
BMS cost(US$)	500	140	279	89	dominated	28	42	29	43
(1,017)	1,500	80	168	51	dominated	16	25	16	26
DES cost(US$)	2,000	45	98	29	dominated	9	15	9	15
(3,250)	4,000	147	296	94	dominated	29	45	31	46
TVR(%)	7.5	177	426	94	dominated	48	71	50	72
(15.7)	30	51	99	39	210	10	18	11	18
ST*(%)	0.0	169	246	144	2,750	22	34	22	34
(0.2)	1.0	43	157	21	dominated	22	34	23	35
* Stent Thrombosis