Cost-effectiveness of drug-eluting stents in patients at high or low risk of major cardiac events in the Basel Stent KostenEffektivitats Trial (BASKET): an 18-month analysis

Background Our aim was to determine whether drug-eluting stents are good value for money in long-term, everyday practice. Methods We did an 18-month cost-effectiveness analysis of the Basel Stent KostenEffektivitats Trial (BASKET), which randomised 826 patients 2:1 to drug-eluting stents (n=545) or to bare-metal stents (281). We used non-parametric bootstrap techniques to determine incremental cost-effectiveness ratios (ICERs) of drug-eluting versus bare-metal stents, to compare low-risk (>= 3.0 mm stents in native vessels; n=558, 68%) and high-risk pa ents (<3.0 mm stents/bypass graft stenting; n=268, 32%), and to do sensitivity analyses by altering costs and event rates in the whole Study sample and in predefined subgroups. Quality-adjusted fife-years (QALYs) were assessed by EQ-5D questionnaire (available in 703/826 patients). Findings Overall costs were higher for patients with drug-eluting stents than in those with bare-metal stents ((sic)11808 [SD 400] per patient with drug-eluting stents and (sic)10 450 [592] per patient with bare-metal stents, mean difference (sic)1358 [717], p<0.0001), due to higher stent costs. We calculated an ICER of (sic)64732 to prevent one major adverse cardiac event, and of (sic)40 467 per QALY gained. Stent costs, number of events, and QALYs affected ICERs most, but unrealistic alterations would have been required to achieve acceptable cost-effectiveness. In low-risk patients, the probability of drug-eluting stents achieving an arbitrary ICER of (sic)10 000 or less to prevent one major adverse cardiac event was 0.016; by contrast, it was 0.874 in high-risk patients. Interpretation if used in all patients, drug-eluting stents are not good value for money, even if prices were substantially reduced. Drug-eluting stents are cost effective in patients needing small vessel or bypass graft stenting, but not in those who require large native vessel stenting.