Background
Methods
Inclusion and exclusion criteria
Data extraction
Study | Year | Country | # Analyses | Horizon (months) | Model | Fundingb | Subgroups | Comparison | Price per stent (2012 €) | Price difference DES vs BMS (2012 €) | # Stents per procedure | Quality (%)a |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Ekman et al. [15] | 2004 | Sweden | 66 | 12,24 | DT | Yes | High risk, diabetes, type of lesion, type of vessel | BMS vs | NS | 1.1-1.8 | 41 | |
PES | NS | 693-1271 | ||||||||||
Hill et al. [22] | 2004 | UK | 36 | 12-60 | STM | No | High risk, # vessels | BMS vs | 679 | 1.3,2.4 | 77 | |
DES | 1607 | 929 | ||||||||||
Tarricone et al. [19] | 2004 | Italy | 10 | 12 | DT | Yes | # vessels, diabetes, type of lesion, type of vessel | BMS vs | NS | 1.2 – 2.6 | 46 | |
SES | NS | 0 | ||||||||||
Bowen et al. [21] | 2005 | Canada | 50 | 12 | DT | No | Post MI, diabetes, type of lesion | BMS vs | 531 | 1.23–2.26 | 61 | |
DES | 1681 | 1150 | ||||||||||
Mittmann et al. [13] | 2005 | Canada | 8 | 12 | DT | NS | BMS vs | 522 | 1.5 | 50 | ||
SES | 2062 | 1540 | ||||||||||
PES | 2062 | 1540 | ||||||||||
Shrive et al. [17] | 2005 | Canada | 11 | LT | STM | Yes | Diabetes, age | BMS vs | 430 | 1.05–1.75 | 56 | |
SES | 1246-3114 | 816-2685 | ||||||||||
Mahieu et al. [12] | 2006 | Belgium | 31 | 12 | DT | NS | Diabetes, type of lesion, type of vessel | BMS vs | NS | 1 | 32 | |
SES | NS | 731-1306 | ||||||||||
PES | NS | 731-1306 | ||||||||||
Hill et al. [2] | 2007 | UK | 172 | 12 | STM | No | High risk, elective | BMS vs | 485 | 1-2 | 80 | |
SES | 1700-1774 | 1215-1289 | ||||||||||
PES | 1621-1696 | 1136-1211 | ||||||||||
Kuukasjarvi et al. [23] | 2007 | Finland | 2 | 24 | DT | No | BMS vs | NS | NS | 33 | ||
DES | NS | NS | ||||||||||
Neyt et al. [8] | 2007 | Belgium | 59 | 12 | DT | NS | Diabetes, # vessels, type of lesion | BMS vs | 553-1106 | 1.09–1.97 | 72 | |
DES | 553-1659 | 0-1106 | ||||||||||
Polanczyk et al. [18] | 2007 | Brazil | 4 | 12, LT | STM | Yes | BMS vs | 831-1390 | 1.2 | 56 | ||
SES | 3169 | 1779, 2337 | ||||||||||
Bischof et al. [14] | 2009 | USA | 4 | 36 | STM | No | BMS vs | NS | NS | NS | 76 | |
SES | NS | |||||||||||
PES | NS | |||||||||||
Goeree et al.[24] | 2009 | Canada | 45 | 24 | DT | No | Diabetes, type of lesion, type of vessel | BMS vs | 470 | 1.1–2.37 | 52 | |
DES | 1486 | 391-1016 | ||||||||||
Ferreira et al. [16] | 2010 | Brazil | 1 | 26 | DT | No | BMS vs | 1883 | NS | 36 | ||
PES | 5272 | 3390 | ||||||||||
2010 | Austria | 6 | 84 | DES | No | Diabetes, type of lesion | BMS vs | NS | 1.24 | 47 | ||
DES | NS | NS | ||||||||||
Remak et al. [20] | 2010 | UK | 3 | 48 | STM | Yes | BMS vs | 433 | 1.11 | 62 | ||
ZES | 1175 | 742 | 1.12-1.4 |
Analysis
Results
Descriptive characteristics
Total (CEAs & CUAs) (N = 16) | CEAs (N = 9) | CUAs (N = 11) | |
---|---|---|---|
Average ± SD | Average ± SD | Average ± SD | |
Incremental outcomes
| |||
Incremental costs | €982 ± €894 | ||
Incremental QALYs | 0.0042 ± 0.008 | ||
Incremental repeat revascularization avoided | 0.0958 ± 0.0521 | ||
Input parameters
| |||
Number of stents per procedure | 1.503 ± 0.367 | 1.382 ± 0.355 | 1.540 ± 0.364 |
Price of DES stent | € 1,654 ± € 390 | € 1,912 ± € 672 | € 1,614 ± € 307 |
Price of BMS stent | € 555 ± € 166 | € 670 ± € 307 | € 534 ± € 114 |
Price difference between stents | € 1,085 ± € 337 | € 1,189 ± € 336 | € 1,056 ± € 331 |
Price of DES procedure (incl. stents) | € 6,328 ± € 2,509 | € 7,811 ± € 1,475 | € 5,998 ± € 2,573 |
Price of BMS procedure (incl. stents) | € 4,442 ± € 2,195 | € 6,259 ± € 1,536 | € 4,160 ± € 2,138 |
Cost difference between the procedures | € 1,787 ± € 686 | € 1,551 ± € 805 | € 1,840 ± € 647 |
Probability restenosis BMS | 0.142 ± 0.076 | 0.148 ± 0.055 | 0.140 ± 0.081 |
Probability restenosis DES | 0.064 ± 0.038 | 0.056 ± 0.027 | 0.068 ± 0.041 |
Relative risk reduction DES vs. BMS | 0.484 ± 0.204 | 0.578 ± 0.214 | 0.449 ± 0.189 |
Quality (0-100 %)*
| |||
Total | 59.5 ± 15.4 | ||
Structure | 62.5 ± 16.1 | ||
Data | 56.7 ± 21.6 | ||
Consistency | 55.1 ± 20.8 |
Outcome repeat revascularizations avoided
Bivariate | |||
---|---|---|---|
∆ Repeat revascularization d | |||
Covariates | β | N | se |
120 | |||
Population
| |||
Age | 70 | ||
Age >75 | NA | 0 | NA |
Age 65-75 | −0.018 | 8 | 0.05 |
Age < 65 | ref | 62 | |
Complex lesion (yes vs. no) | 0.029* | 56 | 0.007 |
Complex vessel (yes vs. no) | 0.042* | 27 | 0.012 |
Multi vessel disease (yes vs. no) | 0.019* | 12 | 0.007 |
Diabetes (yes vs. no) | 0.02* | 64 | 0.007 |
Post MI (yes vs. no) | 0.007 | 25 | 0.011 |
Elective (yes vs. no) | NA | 0 | NA |
High risk (yes vs. no) | NA | 0 | NA |
Intervention
| |||
Type DES | 120 | ||
Sirolimus eluting stent | 0.102* | 21 | 0.014 |
Paclitaxel eluting stent | 0.063* | 56 | 0.014 |
Zotarolimus eluting stent | NA | 0 | NA |
Drug eluting stent in general | ref | 43 | |
Study characteristics
| |||
Country | 120 | ||
Canada | −0.099 | 42 | 0.056 |
Sweden | −0.036 | 27 | 0.068 |
Brazil | −0.08 | 5 | 0.072 |
Finland | −0.04 | 1 | 0.072 |
Belgium | −0.07 | 39 | 0.059 |
Italy | ref | 10 | |
Study year | 0.01 | 120 | 0.008 |
Horizon >1 year (yes vs. no) | −0.006 | 120 | 0.021 |
Horizon (months) b | <0.001 | ||
Type of study (CUA vs. CEA) | NA | NA | NA |
Model | 120 | ||
Markov model | NA | 0 | NA |
Discrete event simulation model | NA | 0 | NA |
Decision tree | NA | 120 | NA |
Perspective | 120 | ||
Health care provider perspective | 0.004 | 6 | 0.017 |
Health care sector perspective | 0.04 | 31 | 0.05 |
Non-public perspective | NA | 0 | NA |
Health care payer perspective | ref | 83 | |
Funding | 73 | ||
No | 0.034 | 27 | 0.045 |
Yes | 46 | ||
Both Industry and No industry | NA | 0 | NA |
Industry | 0.102* | 37 | 0.046 |
No industry | ref | 9 | |
Discounting (yes vs. no)c | −0.084* | 11 | 0.026 |
Input parameters
| |||
Number of stents used during the procedure | 0.033* | 111 | 0.01 |
Price difference between stents | NA | NA | NA |
Price of BMS stent | NA | NA | NA |
Price of DES stent | NA | NA | NA |
Costs of BMS procedure (incl. stents) | NA | NA | NA |
Costs of DES procedure (incl. stents) | NA | NA | NA |
Difference in procedure costs | NA | NA | NA |
Probability of restenosis BMS |
0.521*
| 112 | 0.041 |
Probability of restenosis DES | 0.436* | 112 | 0.127 |
Relative risk reduction repeat revascularization |
0.132*
| 112 | 0.018 |
Disutility of undergoing a CABG | NA | NA | NA |
Disutility of undergoing a PCI | NA | NA | NA |
Disutility of experiencing a MI | NA | NA | NA |
Disutility for a patient with angina symptoms | NA | NA | NA |
Quality of life of a patient with angina symptoms | NA | NA | NA |
Quality of life of a patient after revascularization (recovered) | NA | NA | NA |
Quality of life of a patient suffering from restenosis | NA | NA | NA |
Assumptions
| |||
Difference in clopidogrel (medication) usage (yes vs. no) | 0.001 | 45 | 0.015 |
Wait time for revascularization included (yes vs. no) | −0.051 | 77 | 0.048 |
Repeat revascularization is based on angiographic follow-up data (yes vs. no) | 0.082* | 82 | 0.01 |
DES and BMS are not mixed up during a procedure | −0.061 | 120 | 0.047 |
Repeat interventions that occur during time horizon are the result of restenosis | NA | 120 | NA |
There do not exist differences in mortality, thrombosis or MI between DES and BMS | 0.039 | 120 | 0.039 |
The type of repeat revascularization is the same for the DES and BMS treatment groups | −0.071 | 120 | 0.044 |
There does not exist a difference in survival between DES and BMS | 0.015 | 120 | 0.033 |
There does not exist a difference in thrombosis between DES and BMS | 0.039 | 120 | 0.039 |
There does not exist a difference in MI between DES and BMS | 0.046 | 120 | 0.031 |
Structure (%) | −0.145 | 120 | 0.099 |
Data (%) | −0.167* | 120 | 0.066 |
Consistency (%) | −0.153 | 120 | 0.081 |
Total (%) | −0.250* | 120 | 0.087 |
Outcome of incremental QALYs
Bivariate | |||
---|---|---|---|
∆ QALYs | |||
Covariates | β | N | se |
384 | |||
Population
| |||
Age | 190 | ||
Age >75 | 0.029* | 1 | 0.002 |
Age 65-75 | 0.015* | 52 | 0.002 |
Age < 65 | ref | 137 | |
Complex lesion (yes vs. no) | 0.001* | 123 | <0.001 |
Complex vessel (yes vs. no) | 0.001* | 51 | <0.001 |
Multi vessel disease (yes vs. no) | 0.001 | 90 | <0.001 |
Diabetes (yes vs. no) | <0.001 | 135 | <0.001 |
Post MI (yes vs. no) | <0.001 | 25 | 0.001 |
Elective (yes vs. no) | −0.001* | 208 | <0.001 |
High risk (yes vs. no) | 0.004* | 127 | 0.001 |
Intervention
| |||
Type DES | 384 | ||
Sirolimus eluting stent | 0.01 | 75 | 0.009 |
Paclitaxel eluting stent | 0.011 | 151 | 0.009 |
Zotarolimus eluting stent | 0.025 | 3 | 0.015 |
Drug eluting stent in general | ref | 155 | |
Study characteristics
| |||
Country | 384 | ||
United Kingdom | 0.011 | 211 | 0.015 |
United States | 0.001 | 4 | 0.019 |
Canada | 0.016 | 72 | 0.015 |
Sweden | 0.002 | 39 | 0.019 |
Austria | 0.001 | 6 | 0.019 |
Finland | 0.005 | 1 | 0.019 |
Belgium | 51 | ||
Study year | 0.001 | 384 | 0.002 |
Horizon >1 year (yes vs. no) | 0.002 | 384 | 0.001 |
Horizon (months) b | <0.001* | 373 | <0.001 |
Type of study (CUA vs. CEA) | NA | NA | NA |
Model | 384 | ||
Markov model | 0.014 | 226 | 0.008 |
Discrete event simulation model | 0.001 | 6 | 0.014 |
Decision tree | ref | 152 | |
Perspective | 384 | ||
Health care provider perspective | 0.006 | 7 | 0.012 |
Health care sector perspective | NA | 0 | NA |
Non-public perspective | NA | 0 | NA |
Health care payer perspective | ref | 377 | |
Funding | 333 | ||
No | −0.001 | 30 | |
Yes | 303 | ||
Both Industry and No industry | 0.043* | 11 | 0.008 |
Industry | 0.012 | 42 | 0.006 |
No industry | ref | 250 | |
Discounting (yes vs. no)c | 0.015 | 90 | 0.013 |
Input parameters
| |||
Number of stents used during the procedure | 0.001 | 379 | 0 |
Price difference between stents | NA | NA | NA |
Price of BMS stent | NA | NA | NA |
Price of DES stent | NA | NA | NA |
Costs of BMS procedure (incl. stents) | NA | NA | NA |
Costs of DES procedure (incl. stents) | NA | NA | NA |
Difference in procedure costs | NA | NA | NA |
Probability of restenosis BMS | 0.024* | 366 | 0.001 |
Probability of restenosis DES | 0.005 | 282 | 0.004 |
Relative risk reduction repeat revascularization | 0.007* | 300 | 0.001 |
Disutility of undergoing a CABG | −0.747* | 254 | 0.163 |
Disutility of undergoing a PCI | −0.107 | 254 | 0.433 |
Disutility of experiencing a MI | −0.021 | 40 | 0.097 |
Disutility for a patient with angina symptoms | −0.012 | 78 | 0.013 |
Quality of life of a patient with angina symptoms | −0.231* | 338 | 0.04 |
Quality of life of a patient after revascularization (recovered) | −0.24* | 380 | 0.024 |
Quality of life of a patient suffering from restenosis | −0.254* | 144 | 0.031 |
Assumptions
| |||
Difference in clopidogrel (medication) usage (yes vs. no) | <0.001 | 270 | 0.001 |
Wait time for revascularization included (yes vs. no) | −0.012* | 336 | 0.006 |
Repeat revascularization is based on angiographic follow-up data (yes vs. no) | 0.013* | 329 | 0.006 |
DES and BMS are not mixed up during a procedure | 0.002 | 384 | 0.01 |
Repeat interventions that occur during time horizon are the result of restenosis | 0.02* | 384 | 0.01 |
There do not exist differences in mortality, thrombosis or MI between DES and BMS | −0.003 | 384 | 0.016 |
The type of repeat revascularization is the same for the DES and BMS treatment groups | −0.008 | 384 | 0.016 |
There does not exist a difference in survival between DES and BMS | 0.001 | 384 | 0.002 |
There does not exist a difference in thrombosis between DES and BMS | −0.003 | 384 | 0.016 |
There does not exist a difference in MI between DES and BMS | −0.006 | 384 | 0.01 |
Structure (%) | −0.006 | 384 | 0.033 |
Data (%) | 0.006 | 384 | 0.024 |
Consistency (%) | −0.018 | 384 | 0.02 |
Total (%) | <0.001 | 384 | 0.032 |
Outcome incremental costs
Bivariate | |||
---|---|---|---|
∆ Costs (2012€) | |||
Covariates | β | N | se |
437 | |||
Population
| |||
Age | 190 | ||
Age >75 | 315 | 1 | 901 |
Age 65-75 | −31 | 52 | 695 |
Age < 65 | ref | 137 | |
Complex lesion (yes vs. no) | 172* | 134 | 85 |
Complex vessel (yes vs. no) | −5 | 62 | 116 |
Multi vessel disease (yes vs. no) | 122 | 98 | 200 |
Diabetes (yes vs. no) | −217* | 150 | 78 |
Post MI (yes vs. no) | −88 | 25 | 88 |
Elective (yes vs. no) | 346* | 208 | 109 |
High risk (yes vs. no) | −291 | 127 | 193 |
Intervention
| |||
Type DES | 437 | ||
Sirolimus eluting stent | 551 | 100 | 636 |
Paclitaxel eluting stent | 379 | 180 | 636 |
Zotarolimus eluting stent | −324 | 3 | 1321 |
Drug eluting stent in general | ref | 154 | |
Study characteristics
| |||
Country | 437 | ||
United Kingdom | 2147* | 211 | 836 |
United States | 4425* | 4 | 1050 |
Canada | 2922* | 79 | 808 |
Sweden | 1745 | 39 | 1016 |
Brazil | 3444* | 5 | 932 |
Austria | 1752 | 6 | 1035 |
Finland | 2051 | 1 | 1174 |
Belgium | 1698 | 82 | 879 |
Italy | ref | 10 | |
Study year | −190 | 437 | 137 |
Horizon >1 year (yes vs. no) | −479 | 437 | 277 |
Horizon (months) b | −32* | 414 | 6 |
Type of study (CUA vs. CEA) | −194* | 507 | 86 |
Model | 437 | ||
Markov model | 613 | 230 | 611 |
Discrete event simulation model | −435 | 6 | 1219 |
Decision tree | ref | 201 | |
Perspective | 437 | ||
Health care provider perspective | 266 | 14 | 363 |
Health care sector perspective | −1332 | 31 | 1151 |
Non-public perspective | −1057 | 2 | 670 |
Health care payer perspective | ref | 390 | |
Funding | 347 | ||
No | 1480* | 31 | 634 |
Yes | 316 | ||
Both Industry and No industry | 1246 | 11 | 1041 |
Industry | −621 | 56 | 663 |
No industry | ref | 249 | |
Discounting (yes vs. no)c | 1071 | 91 | 713 |
Input parameters
| |||
Number of stents used during the procedure | 708* | 424 | 83 |
Price difference between stents | 1.264* | 418 | 0.13 |
Price of BMS stent | 0.503* | 320 | 0.354 |
Price of DES stent | 1.001* | 312 | 0.152 |
Costs of BMS procedure (incl. stents) | 0.339* | 278 | 0.092 |
Costs of DES procedure (incl. stents) | 0.412* | 278 | 0.053 |
Difference in procedure costs | 0.799* | 278 | 0.075 |
Probability of restenosis BMS |
−3072*
| 407 | 322 |
Probability of restenosis DES | −1907* | 323 | 899 |
Relative risk reduction repeat revascularization |
−1676*
| 341 | 250 |
Disutility of undergoing a CABG | NA | NA | NA |
Disutility of undergoing a PCI | NA | NA | NA |
Disutility of experiencing a MI | NA | NA | NA |
Disutility for a patient with angina symptoms | NA | NA | NA |
Quality of life of a patient with angina symptoms | NA | NA | NA |
Quality of life of a patient after revascularization (recovered) | NA | NA | NA |
Quality of life of a patient suffering from restenosis | NA | NA | NA |
Assumptions
| |||
Difference in clopidogrel (medication) usage (yes vs. no) | 181 | 279 | 216 |
Wait time for revascularization included (yes vs. no) | −733 | 347 | 486 |
Repeat revascularization is based on angiographic follow-up data (yes vs. no) | −593 | 372 | 492 |
DES and BMS are not mixed up during a procedure | −542 | 437 | 741 |
Repeat interventions that occur during time horizon are the result of restenosis | 855 | 437 | 841 |
There do not exist differences in mortality, thrombosis or MI between DES and BMS | −980 | 437 | 878 |
The type of repeat revascularization is the same for the DES and BMS treatment groups | 501 | 437 | 1187 |
There does not exist a difference in survival between DES and BMS | −238 | 437 | 426 |
There does not exist a difference in thrombosis between DES and BMS | −589 | 437 | 754 |
There does not exist a difference in MI between DES and BMS | −595 | 437 | 665 |
Structure (%) | 2154 | 437 | 1819 |
Data (%) | 1670 | 437 | 1318 |
Consistency (%) | 718 | 437 | 1463 |
Total (%) | 2761 | 437 | 1804 |