After Stent Placement: What Happens with Patient Care?Posted on: 09.26.19
Patient care after stent placement plays a critical role, both in their recovery and in preventing further issues.
However, recent studies have found that many patients aren’t getting the care that they need post-placement. Just one in three patients enroll in recommended cardiac rehabilitation after their stent placement, according to a Michigan study reported in the Journal of the American College of Cardiology.
And yet, accessing aftercare may be one of the best things a patient can do to improve their health:
“For reducing deaths and increasing quality of life, cardiac rehab exceeds any pill, any procedure,” says Dr. Daniel Forman, Director of Exercise Testing Lab at Brigham and Women’s Hospital and an Assistant Professor at Harvard Medical School. “Whether it’s getting a patient through a heart attack, placing a stent, or repairing a heart valve, what helped people get through their cardiac event will only be meaningful if we maintain that benefit. Cardiac rehab is an opportunity to do just that.” (Source)
With around 965,000 cardiac stents placed each year, lack of aftercare can represent a significant risk to patients and to the practices that care for them. Overall health of patients is a concern, as are readmission rates for healthcare facilities.
Why patients don’t get post-stent care
There are a number of key reasons why patients don’t get post-stent care:
Cost: This is identified as the number one barrier in most cases where patients don’t seek aftercare. In the Michigan study, patients covered by Medicare fee-for-service or by Medicaid were less likely to take up rehabilitation. In other cases, insurance co-pays are too much for them to manage, or they may be uninsured. (Uninsured rates across all age groups have risen). Most rehab programs encourage attendance two or three days per week for at least twelve weeks – those costs soon add up.
No “acute” reason for attendance: Patients in the Michigan study were more likely to attend if they had an acute condition that led to the stent, whereas patients with conditions such as diabetes or peripheral artery disease were less likely to attend.
Accessibility: In many cities, cardiac rehabilitation centers are few and far between. Insurance reimbursement for the professionals in the clinics is often low, which can be a contributing factor to how much is on offer.
Patients may have to travel great distances, or they may have trouble getting to a rehabilitation center that is outside of their regular route. Interestingly, the Michigan study found that geography played a role, but it wasn’t about distance from their home to the rehabilitation center. Patients were more likely to attend rehabilitation if it was within two miles of the site where their PCI procedure took place.
Program Availability: There aren’t enough rehab programs for qualifying patients. An NPR story revealed: “A recent study in the Journal of Cardiopulmonary Rehabilitation and Prevention surveyed 812 existing cardiac rehab programs across the nation and found that even if they were expanded modestly and operated at capacity, the existing programs could serve only 47 percent of qualifying patients.”
Misperceptions about cardiac rehabilitation: Patients might assume that cardiac rehabilitation means working out in a gym. If they have a prior aversion to the gym, or a disability that makes working out difficult, they may not attend. This comes back to patient education and ensuring they understand all facets of cardiac rehabilitation.
Consequences of missed rehabilitation
Mortality is the most significant consequence of skipping rehabilitation after the placement of a cardiac stent. Studies have shown that cardiac rehabilitation patients see a 45 to 47 percent decrease in mortality rates compared to those who don’t participate. There is a 25 percent reduction in all-cause mortality and decreased mortality five years past participation.
Patients also miss out on better quality of life that participation in cardiac rehabilitation can bring. Improved fitness, wellness, and overall health are known benefits of rehabilitation, often prolonging life or the time between stent placement and the need for bypass surgery.
For both patients and healthcare facilities, a major consequence is the increased number of readmissions that are associated with missing rehabilitation. Participating in cardiac rehabilitation reduces readmissions by up to 25 percent, also saving millions of dollars in fees.
Under the Affordable Care Act, hospitals face financial penalties if too many cardiac patients are readmitted soon after discharge. The incentive is definitely there for both patients and healthcare organizations to seek rehabilitation for better outcomes.
Getting more patients into rehabilitation
What can be done about the vast numbers who don’t attend post-care after stent placement? One thing we already know from the Michigan study is that simply getting physicians on board with recommending rehabilitation works. Previously, some studies have shown that physician referrals to cardiac rehabilitation were as low as twenty percent.
Ensuring patients have all the information they need and the support to be comfortable with rehabilitation is another important strategy. A welcoming environment and trained staff to ease their fears helps.
A recent joint scientific statement from the ACC, the American Heart Association, and the American Association of Cardiovascular and Pulmonary Rehabilitation published May 13, 2019 in the Journal of the American College of Cardiology stated that home-based cardiac rehabilitation may be a reasonable option for some patients.
The overall lack of accessibility and cost barriers for many patients highlight the importance of finding alternatives to attending clinics and presenting new ways of delivering care. The statement authors found that:
“…although the science behind home-based cardiac rehab is relatively new and less developed, its findings are generally consistent with those reported for center-based cardiac rehab.”
While they acknowledge that lack of reimbursements may be a barrier, they state that as technology improves to allow home-based cardiac rehabilitation, more needs to be done to work with policymakers and ensure home-based is a covered option.
Cardiac rehabilitation post-stent placement is critical for most patients, yet it is grossly under-attended. There are several barriers at play, including accessibility, cost, education and referrals.
Lack of participation in rehabilitation leads to poorer health outcomes and higher incidences of readmissions. This is bad news for physicians and their patients, with the physician perspective including penalties for readmissions.
While studies point to an overall shortage of cardiac rehabilitation being available across the country, home-based care may be a viable alternative. This is a space to watch – we need alternative options that get more patients the post-care that they need.
New Studies Highlight Innovations in Drug-Eluting Stent ResearchPosted on: 07.18.19
The recently released Stent Market Report highlights steady growth happening in the stent industry. The global stent market is expected to reach an estimated $10.8 billion by 2024, with a CAGR of 3.3% from 2019 to 2024.
This growth is largely driven by increasing interventional cardiology and peripheral vascular procedures. There has also been a rising adoption of technological advancements in stents in an effort to reduce treatment duration for high-risk conventional surgical patients.
Some emerging trends that are making their mark include increasing use of the bioreabsorbable stent, adoption of co-polymers as raw materials, and increasing adoption of bifurcated stents.
There is also a corresponding increase in cases of cardiovascular disorders, which leads analysts to forecast that growth will be above average. The drug-eluting stent is forecasted to remain the largest market by technology due to lower restenosis rate after surgery. The bioreabsorbable stent is predicted to be the highest growth market, while North America is set to remain the largest geographic market.
New Studies Feature Drug-Eluting Stent Innovations
Here are a few recently published studies that highlight innovations and news related to drug-eluting stents.
IVUS guided stent implantation for CKD patients
A study out of Nanjing Medical University, China examined the effects of intravascular ultrasound (IVUS) guided drug-eluting stent (DES) implantation on patients with chronic kidney disease (CKD).
While previous trials have established the benefits of IVUS guided implantation over traditional angiography guidance for patients with complex lesions, use of the procedure has been controversial for patients with CKD due to longer procedural time and perceived potential risks of acute renal failure and atheroembolism.
The study assessed 1,443 patients of whom 723 underwent IVUS-guided DES implantations and 720 underwent angiography-guided DES implantations from August 2014 to May 2017. This study included 349 CKD patients.
The results showed that at 12 months, the target vessel failure (TVF) among CKD patients was significantly higher than non-CKD patients at 7.2% versus 3.2%. Of those in the CKD group, there were 25 total TVFs with 7 in the IVUS group and 18 in the angiography group.
The reduced risk of TVF in the IVUS group for CKD patients was mainly driven by the lower risk of Target Vessel MI (TVMI) (0.6 vs. 3.6 percent) and Target Vessel Revascularization (TVR) (1.1 vs. 4.7 percent). Broader studies are being called upon.
This is a significant development to watch with CKD pegged as a growing worldwide health issue. CKD is common among US adults, with around 15% estimated to have the condition, although an estimated nine out of ten don’t know they have it. CKD brings with it a higher risk of heart disease and stroke.
Cost-effective drug-eluting stent just as good as more expensive competitor
A study out of Europe was recently published in Lancet comparing a cheaper, Indian-made drug-eluting stent to a costlier American-made stent.
The trial involved more than 1,400 European patients, with half receiving the Supraflex (Indian-made stent) and half receiving Xience (made by Abbot in the United States). The European government bought the stents in 2017 after noting the wide price variation on the market. One of their goals was to ensure life-saving devices were affordable.
The results of the study showed that the outcome remained the same for both trial groups after twelve months. This is promising as an option to keep costs down for patients who require a stent. Further studies are to be conducted on diabetic patients who require angioplasty.
Drug-eluting stents more effective than bare metal stents
While new-generation drug-eluting stents (DES) have been investigated up against earlier generation DES to show similar efficacy and superior safety, they had not been compared to bare metal stents (BMS).
A study recently published in Lancet concludes that; “The performance of new-generation DES in the first year after implantation means that BMS should no longer be considered the gold standard for safety.”
In comparing new-generation DES to BMS, the following findings came out:
“We obtained individual data for 26 616 patients in 20 randomized trials. Mean follow-up was 3·2 (SD 1·8) years. The risk of the primary outcome was reduced in DES recipients compared with BMS recipients (HR 0·84, 95% CI 0·78–0·90, p<0·001) owing to a reduced risk of myocardial infarction (0·79, 0·71–0·88, p<0·001) and a possible slight but non-significant cardiac mortality benefit (0·89, 0·78–1·01, p=0·075). All-cause death was unaffected (HR with DES 0·96, 95% CI 0·88–1·05, p=0·358), but risk was lowered for definite stent thrombosis (0·63, 0·50–0·80, p<0·001) and target-vessel revascularization (0·55, 0·50–0·60, p<0·001). We saw a time-dependent treatment effect, with DES being associated with lower risk of the primary outcome than BMS up to 1 year after placement. While the effect was maintained in the longer term, there was no further divergence from BMS after 1 year.”
The study interpretation ends with the following recommendation:
“Further development of DES technology should target improvements in clinical outcomes beyond 1 year.”
Ultrathin-strut DES beneficial for small coronary vessels
A recent presentation at EuroPCR by Clemens von Birgelen, MD, PhD, FESC, director of the department of cardiology at Thoraxcentrum Twente and professor of cardiology at the University of Twente in the Netherlands, showed that ultrathin-strut DES are beneficial for cardiac patients with small coronary vessels.
The three-year study examined 1,452 patients, each of whom had at least one small vessel lesion. Patients with small coronary vessels had a lower rate of target lesion revascularization if they were implanted with an ultrathin-strut sirolimus-eluting stent compared with a thin-strut zotarolimus-eluting stent.
“Small coronary vessel PCI has an increased adverse event risk but is performed in many patients,” von Birgelen said during his presentation. “Newer DES, such as ultrathin strut Orsiro and very thin strut Synergy, have substantially thinner struts than earlier DES. This may be particularly advantageous in small vessels, due to the greater relative impact of strut size on lumen obstruction.”
There are a number of interesting studies coming out on drug-eluting stent use and improvements to how they are placed and used. It will be interesting to monitor how these develop further and the implications for the US market.
Overall, the cardiac stent market is set to grow steadily, with increasing use of interventional cardiology helping to drive it. Expect to see more product innovations and work to improve long-term outcomes.