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Second Heart Surgery Costly to Medicare

Researchers suggest drug-laced stents may save money

MONDAY, June 28, 2004 (HealthDayNews) -- If you've had angioplasty to open a clogged heart artery, chances are you also had a stent implanted during the procedure to help ward off new blockages.

This procedure is usually successful, but because the artery can become blocked again through a process called restenosis, many patients will have to have the procedure redone within a year. These second procedures add a substantial amount to Medicare costs and may not be for everyone, a new study says.

"Among Medicare patients, about 17 percent needed another angioplasty or bypass operation during the year following their first procedure," said lead author Dr. David J. Cohen, an associate professor of medicine at Harvard Medical School.

Of these patients, 14 percent develop a blockage at the site where the stent was placed, he added. "The cost of doing the second procedure is about $19,000," Cohen said.

A stent is a wire mesh tube used to prop open an artery that has been cleared using angioplasty. During the procedure, the stent is put over a balloon catheter and moved to the blocked part of the artery. Then the balloon is inflated, expanding the stent. The stent then locks in place and forms a scaffold that keeps the artery open.

Cohen's team collected data from the Medicare Standard Analytic File on 9,868 patients who had angioplasty in 1998, according to the report in the June 29 online issue of Circulation.

"If we had treatments that could substantially reduce restenosis, we could offset a lot of cost for the health-care system," Cohen said.

Cohen believes the advent of drug-eluting stents, which release medication that can prevent restenosis, might go a long way to reducing the problem.

"These drug-eluting stents look like they are very promising for reducing the rates of restenosis by 10 to 20 percent," he said.

However, drug-releasing stents cost about $3,000, compared to the $1,000 price tag of a bare metal stent. Cohen said the price of drug-eluting stents has been dropping. "In a couple of years," he predicted, "the price will be low enough to fully offset the additional cost."

"Restenosis, while less common than many people would have guessed, is very expensive, and therefore it is worth spending money to prevent it," Cohen said.

Boston Scientific Corp., a maker of drug-eluting stents, paid for part of the study, and three of the authors are employees of the company.

Cynthia A. Yock, a research associate at Stanford University and an expert in cost-effectiveness of heart treatments, said the newer stents will go only so far to cut costs. "The opportunity for drug-eluting stents to improve outcomes and costs is only among the 14 percent who have restenosis, and then only among that small portion of patients that a fancy stent can fix, " she said.

"Drug-eluting stents may reduce restenosis to 9 or 10 percent, but given that they are so expensive, it is not clear that they are worth the investment," she added.

Yock noted that part of the problem is how to identify those patients that are likely to have restenosis. There are no clear clinical guidelines as to which patients should get a drug-eluting stent, she said. "So you have to use drug-eluting stents in 100 patients to get a 2 to 3 percent improvement in restenosis," she said. "If you could identify these patients, then it might be worth it."

Yock also said that both Medicare and private insurance cover the use of drug-eluting stents, but physicians complain the reimbursement is too low.

Dr. Jonathan Abrams, a professor of medicine at the University of New Mexico Health Sciences Center, said stents do reduce restenosis.

Abrams believes Medicare is doing the right thing by covering the newer stents. He assumes the use of drug-eluting stents will become standard care, but he believes these stents are not for everyone.

There is probably no choice, he said. "The horse is out of the barn on drug-eluting stents," Abrams added. "But Medicare could limit the number of drug-eluting stents used on a single patient."

Abrams believes that patients who have had restenosis should receive drug-eluting stents, but until a way is found to identify patients likely to have restenosis, drug-eluting stents should not be used on every patient.

"The selection of a drug-eluting stent should be tempered by the assessment of what is the likelihood of the artery in question to be a high or low risk for restenosis," Abrams said.

More information

The U.S. Food and Drug Administration can tell you about stents.

SOURCES: David J. Cohen, M.D., M.Sc., associate professor, medicine, Harvard Medical School, Boston; Cynthia A. Yock, M.S., research associate, Stanford University, Palo Alto, Calif.; Jonathan Abrams, M.D., professor, medicine, Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque; June 29, 2004, online issue, Circulation
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