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A Comparison of Cost of DES Versus BMS in the Treatment of CLI in the United States
Satinderjit S. Locham, MD, Isibor J. Arhuidese, MD, MPH, Besma Nejim, MD, MPH, Tammam Obeid, MD, Christopher Abularrage, MD, Mahmoud Malas, MD, MHS, RPVI, FACS.
John Hopkins Medical Institutes, Baltimore, MD, USA.

Objective(s): Despite significant technical advancement in the last decade, the durability of endovascular management of critical limb ischemia (CLI) remains highly debatable. Drug eluting stents (DES) are being popularized for the management of CLI after its precedent success in coronary intervention. Initial reports on the durability of DES are promising. However little is known on the additional cost of this relatively newer technology. The aim of this study is to compare the cost of the traditional bare metal stents (BMS) to the newly introduced DES in a large cohort of CLI patients. Methods: Using the Premier database (2009-2015), we identified all patients with CLI undergoing DES and BMS. Chi-square, Student’s t-tests, medians test, univariate and multivariable regression analyses were implemented to examine in-hospital cost adjusting for patients’ characteristics and comorbidities. Results: A total of 21,702 patients with CLI underwent revascularization using BMS [20,578 (95%)] or DES [1,124 (5%)]. Majority of patients were male (54%), white (66%) with mean age of 69 ± 12 years. Patients undergoing BMS were more likely to be white, hypertensive and smokers (all p<0.05). There was a significant increase in the proportion of patients undergoing DES and a corresponding decrease in BMS (p<0.001) over the study period (figure). There was an increase in median cost of hospitalization for both groups over time (p<0.001). Median cost was similar for both treatments [BMS: ,093(13,110-30,558), DES: ,745(12,879-30,012), p=0.56]. The adjusted linear regression showed that the overall cost of hospitalization for both stents was higher in Blacks and ,861 higher in Hispanics compared to Whites (Both p<0.05). Additionally, the cost was higher in all regions compared to the Midwest [Adjusted mean difference (95%CI) - South: (205-1,143), Northeast: ,135(2,562-3,709), West: ,992(3,336-4,647), all p<0.05].

Conclusions: In this large cohort of CLI patients, we demonstrated that the cost of endovascular revascularization is determined by factors other than the stent type. Racial and regional disparities in cost were observed after controlling for patient factors. This is the first study to show comparable cost between DES and BMS. More liberal utilization of DES for patients with CLI might be appropriate if favourable durability is confirmed.

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