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NICE guidance on drug-eluting stents for coronary artery disease

  • Last modified date:
    19 August 2008
  • Gateway reference:
    10382

The National Institute for Health and Clinical Excellence (NICE) published technology appraisal guidance on drug-eluting stents for the treatment of coronary artery disease on 23rd July 2008.  The guidance partially updates NICE’s technology appraisal guidance on coronary artery stents published in October 2003.

 

The guidance recommends the use of drug-eluting stents for those patients who are at high risk of requiring further interventions if a conventional bare-metal stent was used instead.  Such patients have a coronary artery less than 3mm in diameter, or the segment of the artery to be treated is longer than 15mm.  The guidance also states that drug-eluting stents should only be used if the price difference between it and a bare metal stent is no more than £300.  NICE’s guidance is available at http://www.nice.org.uk/ta152.

 

Amendment to funding direction

NICE and the NHS Purchasing and Supply Agency (PASA) have advised the Department of Health that drug-eluting stents are often available to NHS organisations below their list price through locally agreed contracts that are usually renewed on an annual basis.  Many NHS organisations whose contracts do not come up for renewal within three months of guidance being published may not, therefore, be able to implement NICE’s revised recommendations within the three months normally permitted by the funding direction. 

 

The Department of Health has considered NICE’s advice and has extended the period within which NHS organisations are required to fund treatments recommended in NICE technology appraisal guidance from

Price differential

The Department of Health is aware that the recommendation relating to the price differential between bare metal and drug-eluting stents could make implementation of the guidance more complex for some NHS organisations.  We have provided some worked examples and frequently asked questions that offer a guide on possible interpretations of NICE’s recommendation in particular circumstances.  This guidance complements the costing tool that NICE has published alongside its guidance and is available at http://www.nice.org.uk/Guidance/TA152/CostTemplate/xls/English

 

Worked examples

Example 1:       A trust does not currently contract for bare-metal stents and has no price with which to calculate the price differential.

 

Suggestion 1:    NICE have published a costing tool which includes mean prices for bare-metal and drug-eluting stents based on an NHS sample gathered during the development of the NICE guidance by NHS PASA.  If a trust has no contract for bare-metal stents and there is no locally-determined mean price available, then we would suggest that these mean prices are used to calculate the price differential.  The costing tool is available at http://www.nice.org.uk/Guidance/TA152/CostTemplate/xls/English.

 

If there is no demand for bare-metal stents, and drug-eluting stents can be procured within the price differential recommended by NICE, then there is no requirement to procure bare-metal stents just to be compliant with NICE’s guidance.

 

Example 2:       A trust currently has contracts with more than one manufacturer of bare-metal/ drug-eluting stents.

 

Suggestion 2:    NICE’s guidance does not prevent a trust from contracting with more than one manufacturer.  Under these circumstances, we would suggest that the trust calculate the price differential on the basis of the average bare-metal stent price.  In the table below, for example, manufacturer 1 and 2’s drug-eluting stents would be within the price differential recommended by NICE, but manufacturer 3’s DES would not.

 

 

   Bare-metal stent  Drug-eluting stent
 Manufacturer 1  £100  £250
 Manufacturer 2  £200  £350
 Manufacturer 3  £250  £550
 Average price   £183    

However, you may also wish to derive a weighted average adjusted for usage of each type of stent, the following example indicates how this might affect the averages:

 

 

   Bare-metal stent  Proportion used  Weighted price
 Manufacturer 1  £100  50%  £50
 Manufacturer 2  £200  40%  £80
 Manufacturer 3  £250  10%  £25
 Weighted average price    100%  £155

FAQs

 

Q.        My drug-eluting stent contract is not yet due to be renegotiated but the price difference between bare metal and drug-eluting stents is greater than £300.  Do I need to seek to renegotiate my drug-eluting stent contracts immediately?

 

A.        No.  The Department appreciates that some NHS organisations will not be in a position to implement NICE’s revised guidance immediately because their current contracts have not expired.  The funding direction for the revised drug-eluting stent guidance has been amended from 3 to 12 months in recognition of this issue. 

 

Q.        My drug-eluting stent contract is not due to be renegotiated for more than 12 months. What should I do?

 

A.        The Department understands that a small minority of NHS organisations have contracts longer than 12 months.  We would suggest that you take advice from your local purchasing manager regarding the implications of terminating any contract early compared with the anticipated savings from a reduced price if current prices do not comply with NICE’s guidance.

 

Q.        Does the amendment to the funding direction mean that NHS organisations don’t have to implement NICE’s guidance for 12 months from the date of publication?

 

A.        The amendment to the funding direction means that NHS organisations are required to make funding available to implement NICE’s guidance within 12 months of final guidance.  This does not mean that NHS organisations have to wait 12 months before guidance is implemented.

 

Q.        My trust does not currently contract for bare metal stents.  What price should we use to calculate the price differential between bare metal and drug-eluting stents?

 

A.        NICE have published a costing tool which includes mean prices for bare-metal and drug-eluting stents based on an NHS sample gathered during the development of the NICE guidance by NHS PASA.  If a trust has no contract for bare-metal stents and there is no locally-determined mean price available, then we would suggest that these mean prices are used to calculate the price differential.  The costing tool is available at http://www.nice.org.uk/Guidance/TA152/CostTemplate/xls/English.

 

If there is no demand for bare-metal stents, and drug-eluting stents can be procured within the price differential recommended by NICE, then there is no requirement to procure bare-metal stents just to be compliant with NICE’s guidance.

 

Q.        My trust currently procures bare metal and drug-eluting stents from more than one manufacturer.  Does the NICE guidance mean that NHS organisations should only contract with one manufacturer and what price should we use to calculate the price differential?

 

A.        NICE’s guidance does not prevent a trust from contracting with more than one manufacturer.  Under these circumstances, we would suggest that the trust calculate the price differential on the basis of the average bare-metal stent price.  The tables above provide some worked examples.

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