If we do not as yet have a “stent” in our heart arteries, the chances are high that we may need one in the near future. A “stent” is a tiny wire mesh tube that props open an artery after a balloon angioplasty to prevent “reclosure”.
But can “stented” arteries reclose? Yes, but the chances are much less.
In about a third of patients who have angioplasty with the “first-generation” stents called “bare metal stents”, the artery can become narrowed in a year. The “second-generation” “drug-eluting stents”, however, help prevent this in 90 % of cases. Recently, approval of “third-generation” “bioresorbable” stents (the so-called “disappearing stents”) has created great excitement; the need for such “stents” arose as it was felt that the necessity for “stents” in the healing artery is only temporary; beyond the first two or three years there are potential disadvantages of a permanent “stent”.
The Wall Street Journal covering the first US implant of “bioresorbable stents” quoted the patient as saying he “really liked the idea that the stent was going to dissolve and be out of there at a time when it was no longer required”. Medical fraternity was agog over the new discovery. But several clinical trials have shown that the new stents are more difficult to implant, are “non-superior” to earlier stents and the cost is prohibitive. But more time is required for the final verdict.
What about the choice of stent if we take “cost” into consideration? Patients ought to know that there is a lot of “commercialism” going on with regard to stents. Therefore the news that “stent prices will soon be capped under the National List of Essential Medicines (NLEM) by the NPPA (National Pharmaceutical Pricing Authority) is good news. But will they? Most patients are forced to pay anything between Rs 60,000 and Rs 1 lakh or more for cardiac drug eluting stents (DES) though the same stents cost Rs 28,000 to Rs 48,000 even in rich European countries and the UK where there is price control or a fair pricing mechanism for medical devices.
As senior doctors point out, almost all the over-priced stents are imported and hence the government has the “bill of entry” giving the price at which the stent is being imported which typically is a third of the price charged to patients or even less. Yet, the government has done nothing to stop companies and hospitals from looting patients.
The Maharashtra FDA report cites the example of drug eluting stents manufactured by Abbotts Vascular Devices Holland BV, a Holland-based firm. These stents were imported into India by Abbotts Healthcare Pvt Ltd at Rs 40,710 and sold to the distributor Sinocare at Rs 73,440 against a marked MRP of Rs 1.5 lakh. The distributor then sold it at Rs 1.1 lakh to Hinduja hospital, which in turn charged the patient Rs 1.2 lakh, a near three-fold jump over the import price.
And many may be unaware that Indian companies manufacture stents which are second to none. Although some cardiologists allege that Indian stents do not undergo rigorous trials, a well-known doctor from Mumbai is on record that Indian stents are as good as the foreign ones; as such they get exported first and then they come back to our country at ten times the price. All the medical hospitals and the Government do not give recognition to these Indian stent manufacturers as foreign suppliers give bribes in crores to politicians. Many people have given up trying to clean the system.
Currently, over 5 lakh stents are used annually in India. Of this, around 60% are imported whereas less than 40% are manufactured locally. There is a large gap between products sold by multinationals and domestic companies. When a patient undergoes a coronary angioplasty at a private Hospital, even on the angiography table, the patient is told by the interventionist: “We keep three types of stents, the prices varying from Rs 80,000 to Rs 1.5 lakhs. Which one would you like me to use?” Faced with a do-or-die situation the tamed and helpless patient mumbles: “Use the most expensive one” laboring under the impression that cheaper stents are worse and the costlier ones are the best”… Many regret later!
Recently, when Dr. Guruprasad Naik, the Head of Interventional Cardiology at the Goa Medical College, a reputed, world-famous Cardiologist, gave us a lecture on “Coronary Angioplasties” he revealed that the GMC uses the imported Xience Drug eluting stents which are supplied to them. {How transparent the process of purchasing stents at the GMC from the suppliers is we don’t know. It will be worthwhile to know if there are kickbacks, as it is ultimately taxpayer’s money (comment is mine)}. But what I liked the most is that Guruprasad candidly and emphatically stated, “Let the patients not get fooled by the price of the stent. I can bet that some cheaper models are as good as the most expensive ones. All they require is a little more hard work on the part of the interventionist and the job is done”. I say kudos to Dr. Guruprasad, a very humble, honest and first-class interventionist.
(Dr Francisco Colaço is a senior most consulting
physician, pioneer of Echocardiography in Goa)
