JACC: Socio-economic factors of patients impact DES use
 |
While recent data show that DES reduce the need for repeat revascularization and restenosis compared to bare-metal stents (BMS), DES also may produce delays in re-endothelialization, creating a potential risk for stent thrombosis. Due to these findings, guidelines recommend that DES only be used in patients with access to dual-antiplatelet therapy with aspirin and clopidogrel (Plavix, Sanofi-Aventis/Bristol-Myers Squibb) for 12 months in PCI patients treated with DES.
“This decidedly vague recommendation raises questions about the impact of patient-level socio-economic factors upon the decision to use DES,” the authors wrote.
To help answer these questions, Michael A. Gaglia, Jr., MD, of the Washington Hospital Center in Washington, D.C., and colleagues evaluated 12,584 patients undergoing any stent procedure between April 23, 2003, and June 22, 2009, at a single center.
Stent selection was operator-based and the researchers merged the stent database with the hospital's billing department to segregate by insurance type: private (48.9 percent), Medicare (45.2 percent), Medicaid (3.7 percent) and uninsured (2.2 percent).
A further breakdown of patients showed that 66 percent were Caucasian, 26 percent African-American, 3.2 percent Asian, 1.1 percent Hispanic and .4 percent were Native American.
Overall, 9,389 (74.6%) patients received one or more DES. Broken down by insurance type, 78.5 percent of those with private insurance received one or more DES, 72.3 percent with Medicare, 60.2 percent with Medicaid and 60.5 percent without insurance.
Medicaid beneficiaries and the uninsured were least likely to be treated with a DES.
Additionally, results showed that African-American patients were less likely to be treated with DES compared to non-African-Americans, 69.8 percent versus 76.6 percent, respectively. Patients treated with DES were also more likely to be younger, female and present with STEMI, have undergone a prior PCI and have a history of smoking and congestive heart failure.
The investigators said that costs associated with clopidogrel (up to $150 per month) could be a deciding factor when choosing DES over BMS.
The researchers found that Medicaid copayments for clopidogrel within the D.C., Maryland and Virginia area were estimated to be around $1 to $3 per month, while Medicare copayments were $20 to $80 per month. The researchers said that while these numbers may influence the decision to use DES, “this factor alone is inadequate to explain the disparity in patients with Medicaid (or the absence of a disparity in patients with Medicare).”
This analysis does not presume that DES are a panacea for improvement in cardiovascular outcomes,” the authors concluded. “Nevertheless, recognition of this disparity in use and a more nuanced understanding of factors at the patient-provider level that contribute to the disparity would undoubtedly lead to less target vessel revascularization in underserved and minority populations.
In an accompanying editorial, Ronald J. Krone, MD, of the Washington University in St. Louis, Mo., wrote: “Unfortunately, there is no way to determine exactly why the decision was made not to insert the DES. We also do not know if this disparity was present in the early years or only after the importance of dual-antiplatelet therapy became known in late 2008.”
While Krone offered that the higher cost of DES over time compared with BMS could have been a factor, he said, “Reliability of the patient to take dual-antiplatelet therapy without interruption is a major consideration.”
He continued, “The fact that patients without insurance and those on Medicaid were less likely to be given DES does suggest that the physicians at Washington Hospital were making a decision partly based on likelihood to maintain dual-antiplatelet therapy, either on the basis of economics or patient reliability. Until the need for prolonged uninterrupted dual-antiplatelet therapy is reduced, presumably through re-engineering of the stents themselves, or possibly by reducing the cost of the dual-antiplatelet therapy, perhaps to at least the cost comparable to that in other developed countries, these disparities will continue.”