Defining patients at high risk for gastrointestinal hemorrhage after drug-eluting stent placement: a cost utility analysis.

INTRODUCTION The study goal was to evaluate the cost-effectiveness of drug-eluting stent (DES) placement with consideration of gastrointestinal (GI) bleeding risk. DES reduce the need for future coronary revascularization, but require prolonged dual anti-platelet (DAT) therapy, which may increase the risk for GI bleeding. While DES have been found to be cost-effective in patients at average risk for GI bleeding, they may not be the most cost-effective strategy in higher risk patients. METHODS A Markov model was created to compare DES with bare metal stents (BMS). Patients were a hypothetical cohort of 60-year-old individuals with coronary artery stenosis that required nonemergent percutaneous coronary revascularization (PCI). The primary outcomes were the threshold incremental risks of GI bleeding from DAT based on willingness to pay (WTP) of $50,000, $100,000, and $150,000 per quality adjusted life year (QALY) gained. RESULTS For a WTP of $100,000, the relative risk of GI bleeding from DAT could be as high as 10.8 (when compared to aspirin alone) before DES would no longer be cost-effective. In patients with two risk factors for GI bleeding, the threshold relative risk could be as low as 1.6. CONCLUSION In average-risk patients, the risk of GI bleeding from DAT can be substantial without affecting the cost-effectiveness of DES. However, DES are unlikely to be cost-effective in patients with two or more risk factors for GI bleeding.