1.1
There is not enough evidence comparing drug-eluting stents to determine whether price variation between different stents is justified.
1 Recommendations
1.2
NHS trusts should provide access to a range of drug-eluting stents, so that a clinically appropriate stent is available for everyone with coronary artery disease.
1.3
If more than one drug-eluting stent is clinically appropriate, choose the least expensive stent.
What information is needed
More information is needed to justify price variation between different drug-eluting stents. This can be from primary studies or secondary analyses of real-world data comparing stents.
Key outcomes and information that should be captured include:
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intervention-related adverse events
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major adverse cardiac events (MACE)
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target lesion or vessel failure
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acute and chronic stent failure
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target lesion and target vessel revascularisation
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restenosis and stent thrombosis
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the drug-eluting stent used.
All studies and analyses of real-world data should adjust for a range of confounding factors, including:
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the impact of anatomical characteristics of the target vessel and lesion
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the person's age, sex, ethnicity and medical history.
What this means in practice
Considerations for procurement and commissioning
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According to NHS Spend Comparison Service data, cited in a GIRFT cardiology report, in 2021 the NHS spent over £21 million on nearly 86,000 drug-eluting coronary stents in England.
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Although alternative treatments (such as drug-eluting balloons) are in use, clinical experts predict that stents will remain the main treatment for coronary artery disease. So, it is important that the NHS continues to ensure the best value for money when buying drug-eluting stents.
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If a company introduces a new drug-eluting stent or a new stent feature with a higher price to the market, they should provide evidence to justify price variation.
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Commissioners and procurement specialists should work with healthcare professionals in NHS trusts to ensure that a range of stents and their costings at the local level are available.
Considerations for healthcare professionals
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These recommendations are not intended to restrict choice. A clinically appropriate stent should be used, and if more than one is clinically appropriate then the least expensive should be used. This should be the stent that is the best value for the NHS trust.
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When choosing a clinically appropriate drug-eluting stent, healthcare professionals should consider the patient, vessel and lesion characteristics, comorbidities and other factors that can make a stent more suitable.
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These recommendations do not replace clinical reasoning. Healthcare professionals should work with commissioners and procurement specialists who cover their NHS trust to ensure access to a range of drug-eluting stents.
Why the committee made these recommendations
Drug-eluting stents are the main treatment to restore blood flow after a heart attack and to reduce the symptoms of coronary artery disease. NHS trusts have access to a range of drug-eluting stents to ensure that a clinically appropriate stent is always available, and this should continue.
Clinical trial evidence comparing stents shows that different stents have similar stent failure-related clinical outcomes (target lesion revascularisation and target vessel-related myocardial infarction) for people with coronary artery disease. But randomised evidence comparing one stent with another in the scope of this assessment is not available for all the stents.
There are no concerns about the overall cost effectiveness of stents. But because there is uncertainty about the cost-effectiveness estimates, it is not possible to determine whether some drug-eluting stents are more cost effective than others. So, there is not enough evidence to determine whether price variation between different stents is justified. To show any additional value for new stents or new stent features, more evidence comparing different drug-eluting stents would be needed.