一项在对DES应用临床前后的综合分析显示：自DES应用于临床，患者的临床预后得到改善，同时国家对每位患者医保支出却下降。Jason Ryan和同事经过研究发现，从2001年（即DES应用临床前2年）到2004年（即应用DES后1年），患者心血管方面的花费减少了1680$（P=0.001），非心血管领域的投入却增加$2,481（如图示）。

研究者不仅观察应用DES对再次血运重建率和治疗方式的影响，还有对整体医保费用的影响，研究者选取了所有行PCI或者CABG手术的医保患者，根据ICD-9代码，将他们分成2001年组（n=14,362例）和2004年组（n=16,374例）。结果发现，行PCI治疗的患者在入院之后节省的费用较CABG组多，（$1,000 vs. ~$500)

“即使要考虑术后需服用1年双联抗血小板药物而产生的费用，置入DES的医保费用也较低并有意义。”Ryan说。2001年之前和2004年之后，美国在心血管方面花费每年要增加$544,000,000，在非心血管方面的投入增加是$1,360,000,000。

临床疗效

在研究期间，患者死亡率下降4%，差异无统计学意义；但血运重建比率下降7%（P=0.012），MI 发生率下降25%。并且在第一季度之后，患者再次血运重建比例下降17%，P<0.001，有统计学差异。

PCI亚组分析结果 

PCI亚组患者2年分析结果显示，MI率下降了22%，死亡率下降了4%，无统计学意义，再次血运重建率下降14%（P<0.001），并且在第一季度后，此比例变成21%。

CABG亚组分析结果

CABG亚组患者分析结果显示，研究期间患者死亡率、再次血运重建率和第一季度后再次血运重建率方面降低8%、4%、5%，均无统计学差异，整个研究过程中，MI下降率为21%（P=0.002）。

“我们认为这是一个非常有意思的研究，因为它提示我们，导致MI下降可能与DES之外的原因有关，因为此种现象在CABG组也出现了。” Ryan总结道。

（《医心评论》编辑 马秀芹 翻译 刘瑞琦 校对）

Since DES Introduction, Cardiovascular Medicare Costs Down

Key Points:

• Per-patient spending decreased by more than $1,600.

By TCT Daily Staff

Clinical outcomes improved and health-care costs per patient decreased with the introduction of DES, according to a two-year study among Medicare patients in the pre- and post-DES eras.

In the study, which used data from the Medicare Standard Analytic File, Jason Ryan, MD, MPH, of the University of Connecticut Health Center in Farmington (right), and colleagues found that cardiovascular costs decreased between 2001 – two years before DES were introduced – and 2004, a year post-DES introduction (-$1,680; P,.001).

While cardiovascular costs went down, noncardiovascular per-patient costs increased $2,481 (see Figure).

Over nine yearly quarters, the researchers examined not only the effect of DES introduction on overall revascularization rates and treatment patterns, but sought to determine the effect on total health care costs.

They included all Medicare patients hospitalized with coronary revascularization (CABG or PCI) identified by their ICD-9 codes in either 2001 (n=14,362) or 2004 (n=16,374).

They found that patients who had PCI had a higher cost savings (almost $1,000 after index hospitalizaton) than patients who had CABG (~$500 after index hospitalization).

"These cost savings were attenuated, but still significant, even if costs for up to one year of dual antiplatelet therapy after DES implantation were included," Ryan said.

Overall, there was a $544 million increase in cardiovascular spending in the United States and a $1.36 billion overall increase in noncardiovascular costs from the time period preceding 2001 to the time period following the introduction of DES starting in 2004.

Clinical outcomes

There was a 4% decrease in mortality over the study period in all patients, but the difference was not statistically significant. The 7% decrease in repeat revascularizations, though, was significant (P=.012), as was the 25% decrease in MIs (P<.001). There also was a significant decrease of 17% in repeat revascularizations after the first quarter (P<.001), Ryan said.

PCI subgroup

In the subgroup of patients undergoing PCI, two-year data showed a 22% decrease in MIs, a nonsignificant 4% decrease in death, a 14% decrease in repeat revascularizations (P<.001) and a 21% decrease in repeat vascularizations after the first quarter (P<.001).

CABG subgroup

In the subgroup of patients undergoing CABG, there were nonsignificant decreases in death (8%) and repeat revascularizations (4%) over the entire study period as well as repeat revascularizations after the first quarter (5%). In addition, there also was a 21% decrease in MIs (P=.002) over the whole study period.

"We think this is a very telling finding because it suggests that the drop in MI rate [is] probably [related to] do with something other than DES, since we’re seeing it in the CABG cohort as well," Ryan said.

Disclosures:

（source：www.tctmd.com）