ABC | Volume 115, Nº1, July 2020

Short Editorial Oliveira et al. Drug-Eluting Stents for Everyone: Is the Price Worth It? Arq Bras Cardiol. 2020; 115(1):90-91 been performed in a 1-year time horizon and increasing the analysis for 5 years could further improve the cost-effectiveness of DES. The authors concluded that, in the setting of the Brazilian Public Health System, second-generation DES were cost-effective, in accordance with the recommendations of the World Health Organization. Policymakers in health care systems face difficult decisions about how to allocate scarce resources. While ICER are undoubtedly informative in assessing value for money they also need to be considered alongside affordability, budget impact, fairness, feasibility and any other criteria considered important in the local context. ICER threshold values of £20,000 to £30,000 and $50,000 have been conventionally applied in the United Kingdom (UK) and the United States (US), respectively, to guide policymakers in resource allocation decisions. 8,9 If the ICER for a new technology falls below £20 000 (UK) or $50,000 (US) per QALYs gained, that technology is generally recommended for purchase by the national health system. Nonetheless, as stated by Pessoa et al., 7 there is no clear ICER threshold in Brazil as a guidance to incorporate drugs and devices in the public health system. Indeed, the cost-effectiveness thresholds suggested by the WHO for use in low- and middle-income countries is 1 to 3 times GDP per capita 10 by disability adjusted life year (DALY) saved, which is not the outcome considered by the autors. Yet the threshold of R$ 31.587,00 used by Pessoa et al. 7 was initially developed for analysis by DALY saved, then became used as a threshold for the cost-effectiveness limit of analysis by QALY saved and even by life-year saved. But it has not be used as a threshold for cost-effectiveness analyses that consider other outcomes not directly related to survival. Although analyzing a different outcome, Pessoal et al. 7 highlights that the cost increase for providing access to DES is not as high as it has been previously considered. Finally, efforts have recently been made by the Brazilian government to further improved analysis of cost-effectiveness of our major Universal Health Care system in the world. In conclusion, in the light of DES decreasing costs, constant development of new-generation devices and favorable outcomes of recent robust meta-analyses, DES appears to be cost-effective and should, therefore, be adopted as default for routine PCI in the setting of Brazilian Public Health System, like in most developed countries worldwide. 1. Duckers HJ, Nabel EG, Serruys PW, eds. Essentials of restenosis [Internet]. Totowa, NJ: Human Press; 2007. 2. Baschet L, Bourguignon S, Marque S, Durand-Zaleski I, Teiger E, Wilquin F , et al. Cost-effectiveness of drug-eluting stents versus bare-metal stents in patients undergoing percutaneous coronary intervention. Open Heart. 2016;3(2):e000445. 3. Bangalore S, Kumar S, Fusaro M, Amoroso N, Attubato MJ, Feit F, et al. Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials. Circulation. 2012;125(23):2873–91. 4. Schur N, Brugaletta S, Cequier A, Inigues AF. Cost-effectiveness of everolimus-eluting versus bare-metal stents in ST-segment elevation myocardial infarction: An analysis from the EXAMINATION randomized controlled trial. PLoS ONE. 2018;13(8):e0201985. 5. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2019;40(2):87-165. 6. Brasil.Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Comissão Nacional de Incorporação de Tecnologias no SUS (CONITEC). [Internet]. Portaria MS-SCTIE no. 29 de 27/8/2014. [acesso em 2017 dez. 14]. Disponível em: ftp://ftp.saude.sp.gov.br/.../U_PT-MS- SCTIE-29_270814.pdf 7. Pessoa JA, Maia E, Maia F, Oliveira MS, Araújo DV, Ferreira E, Albuquerque DC. Custo-efetividade do Stent Farmacológico na Intervenção Coronariana Percutânea no SUS. Arq Bras Cardiol. 2020; 115(1):80-89. 8. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness— the curious resilience of the $50,000-per-QALY threshold N Engl J Med.2014;371(9):796-7. 9. BertramMY, Lauer JA, De Joncheere K, Edejer T, Hutubessy R, Kieny MP, Hill SR. Cost–effectiveness thresholds: pros and cons. Bull World Health Organ. 2016;94(12):925-30. 10. Claxton K, Martin S, Soares M,Rice N, Smith PC. Written evidence to the House of Commons Health Select Committee on the NICE cost-effectiveness threshold. 2013. [Cited in 2019 Apr 10]. Available from: http://www.publications.parliament.uk/pa/cm201213/cmselect/ cmhealth/782/782vw55.htm. References This is an open-access article distributed under the terms of the Creative Commons Attribution License 91