Cost-effectiveness of coronary stenting in acute myocardial infarction - Results from the stent primary angioplasty in myocardial infarction (Stent-PAMI) trial

Background-Although several randomized trials have demonstrated that coronary stenting improves angiographic and clinical outcomes for patients with acute myocardial infarction (AMI), the cost-effectiveness of this practice is unknown. The objective of the present study was to evaluate the long-term costs and cost-effectiveness (C/E) of coronary stenting compared with primary balloon angioplasty as treatment for AMI. Methods and Results-Between December 1996 and November 1997, 900 patients with AMI were randomized to undergo balloon angioplasty (PTCA, n = 448) or coronary stenting (n = 452). Detailed resource utilization and cost data were collected for each patient's initial hospitalization and for I year after randomization. Compared with conventional PTCA, stenting increased procedural costs by approximate to $2000 per patient ($6538 +/- 1778 versus $4561 +/- 1598, P < 0.001). During the 1-year follow-up period, stenting was associated with significant reductions in the need for repeat revascularization and rehospitalization. Although follow-up costs were significantly lower with stenting ($3613 +/- 7743 versus $4592 +/- 8198, P = 0.03), overall 1-year costs remained approximate to $1000/patient higher with stenting than with PTCA ($20 571 +/- 10 693 versus 19 595 +/- 10 990, P=0.02). The C/E ratio for stenting, compared with PTCA was $10 550 per repeat revascularization avoided. In analyses that incorporated recent changes in stent technology and pricing, the 1-year cost differential fell to < $350/patient, and the C/E ratio improved to $3753 per repeat revascularization avoided. The cost-utility ratio for primary stenting was < $50 000 per quality-adjusted life year gained only if stenting did not increase 1-year mortality by >0.2% compared with PTCA. Conclusions-As performed in Stent-PAMI, primary stenting for AMI increased 1-year medical care costs compared with primary PTCA. The overall cost-effectiveness of primary stenting depends on the societal value attributed to avoidance of symptomatic restenosis, as well as on the relative mortality rates of primary PTCA and stenting.