Willingness To Pay To Eliminate the Risk of Restenosis Following Percutaneous

Coronary Intervention : A Contingent Valuation

Jason R. Guertin, Aihua Liu, Michal Abrahamowicz, David J. Cohen, Salma Ismail,
Jacques LeLorier, James M. Brophy and Stphane Rinfret
Circ Cardiovasc Qual Outcomes 2011;4;46-52; originally published online December 14,
2010;
DOI: 10.1161/CIRCOUTCOMES.109.915421
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Willingness To Pay To Eliminate the Risk of Restenosis

Following Percutaneous Coronary Intervention
A Contingent Valuation
Jason R. Guertin, MSc; Aihua Liu, MSc; Michal Abrahamowicz, PhD;
David J. Cohen, MD, MSc; Salma Ismail, MSc; Jacques LeLorier, MD, PhD;
James M. Brophy, MD, PhD; Stephane Rinfret, MD, SM
BackgroundPercutaneous coronary intervention (PCI) remains limited by the risk of restenosis. Patients perceptions of
the health benefits and value of avoiding restenosis are incompletely known.
Methods and ResultsWe used a contingent valuation approach to assess the willingness to pay (WTP) for a hypothetical
treatment that eliminates the risk of restenosis among 270 PCI patients. Patients were provided with a scenario
describing a baseline 10% or 20% probability of restenosis in the year following the procedure, which could lead to
repeat PCI or, more rarely, bypass surgery, without any increase in mortality. Six different take it or leave it bids
($500, $1000, $1500, $2000, $2500, and $3000) and both risk levels were randomly assigned. Multiple logistic
regression was used to identify independent predictors of a positive response to the WTP question. Using nonparametric
methods, the median WTP to eliminate the risk of restenosis was estimated at $2802. As expected, higher income was
independently associated with a higher probability of a positive response to the WTP question (odds ratio, 2.81; 95%
CI, 1.32 to 5.97). Bids also were independently associated with the probability of being willing to pay, and this
association followed a quadratic effect. Below $1500, bid had little impact on patient answers. However, as prices
increased, the probability of being willing to pay started to decrease sharply.
ConclusionThe potential to eliminate the risk of restenosis, a benign complication, would have substantial value for
patients undergoing PCI. (Circ Cardiovasc Qual Outcomes. 2011;4:46-52.)
Key Words: restenosis stents cost-benefit analysis

ercutaneous coronary intervention (PCI) with stent implantation effectively reduces angina in patients with coronary
artery disease.1 However, benefits of PCI remain limited in the
following year by restenosis, a nonfatal and relatively benign
complication that nevertheless can lead to recurrent symptoms,
repeat revascularization (RR) procedures,2,3 and a decrease in
quality of life (QOL).4 Drug-eluting stents (DES) reduce the risk
of restenosis and subsequent RR procedures by 50% to 75%
compared to bare-metal stents (BMS).5 Despite their efficacy,
there still is debate about whether the increased effectiveness of
DES compared with BMS justifies their incremental cost.6,7

Editorial see p 9
The contingent valuation approach assesses, in monetary
values, all benefits associated with a preferred health state. This
goal may be achieved by asking how much money an individual
would trade to avoid a given decrement in health in a hypothet-

ical market and then determining his or her maximum willingness to pay (WTP) for avoiding this detrimental condition.8 By
doing so, the contingent valuation quantifies, through a single or
a series of questions, all of the benefits arising from avoiding a
detrimental health condition, whether they are gains in leisure or
work time, reduction in pain levels, or any other benefit that may
be achieved by avoiding the detrimental health condition. Although this method may overestimate the value of examined
goods,9 assessing patients WTP for a treatment that provides a
preferred condition can produce additional information on the
impact a condition can have on patient well-being. Contingent
valuation is of particular interest for understanding treatments
that reduce restenosis because the clinical consequences of
restenosis generally are short lived.10 The goal of this project
was to use this technique to measure how much Canadian
patients value treatments that could eliminate restenosis
post-PCI.

Received March 25, 2010; accepted September 13, 2010.

From the Universite de Montreal (J.R.G., J.L.); Centre Hospitalier de lUniversite de Montreal Research Centre (J.R.G., S.I., J.L., S.R.); Department
of Epidemiology, Biostatistics and Occupational Health (A.L., M.A., J.M.B.), McGill University; and Division of Clinical Epidemiology (A.L., M.A.,
J.M.B.) and Division of Cardiology (J.M.B.), McGill University Health Centre, Montreal, Canada; Saint Lukes Mid America Heart Institute (D.J.C.),
Kansas City, Mo; and Institut universitaire de cardiologie et de pneumologie de Quebec (S.R.), Quebec City, Canada.
Guest Editor for this article was Brahmajee K. Nallamothu, MD.
Correspondence to Stephane Rinfret, MD, SM, Clinical and Interventional Cardiology, Multidisciplinary Cardiology Department, Institut universitaire
de cardiologie et de pneumologie de Quebec 2725, Chemin Ste-Foy, Quebec City, Quebec G1V 4G5, Canada. E-mail stephane.rinfret@criucpq.ulaval.ca
2011 American Heart Association, Inc.
Circ Cardiovasc Qual Outcomes is available at http://circoutcomes.ahajournals.org

DOI: 10.1161/CIRCOUTCOMES.109.915421

46
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Guertin et al

WHAT IS KNOWN

Restenosis occurs in 15% of patients undergoing

percutaneous coronary intervention (PCI) with baremetal stents.
In a previous contingent valuation study in the United
States, patients presented with a 30% risk of restenosis
following PCI were willing to pay median amounts of
$273, $366, and $1162 for a 10%, 20%, and 30%
reduction in the risk of restenosis, respectively.

WHAT THIS STUDY ADDS

Our study shows that patients in a public healthcare

system would be willing to pay a median amount of
$CAN 2802 for a procedure that would eliminate the
risk of restenosis following PCI.
Our study also identified that before undergoing
cardiac catheterization followed by ad hoc PCI,
90.7% of patients believed that PCI could prolong
their life span, and 92.2% of patients believed that it
could improve their quality of life.

Methods
Patient Population
Between November 18, 2005, and March 7, 2008, all patients
undergoing cardiac catheterization with ad hoc PCI at the Centre
Hospitalier de lUniversite de Montreal were approached to participate in the study. The only exclusion criteria were (1) patient refusal,
(2) any clinical situation that does not safely allow the administration
of the questionnaire before the catheterization, and (3) inability to
understand French or English. The study protocol was approved by
the hospitals Scientific and Ethical Research Committees, and all
patients provided written informed consent.

Data Collection
Immediately before the planned cardiac catheterization, trained
investigators administered an in-person questionnaire to collect
socioeconomic data, WTP, and health-related QOL assessments.
Clinical data were extracted from patients hospital charts. The
questionnaire also included questions regarding patients perspective
on PCI.

WTP Assessment
We used the contingent valuation method to assess patients WTP for
a hypothetical treatment that would eliminate the risk of restenosis
(and subsequent RR) in the year following a PCI. The question was
asked following an ex post perspective. In other words, the question
was given to patients who require or may directly benefit from the
proposed program.11 We used a closed-ended dichotomous format
question to assess the patients WTP for the proposed program.12,13
With this method, patients were provided a single dichotomous take
it or leave it (ie, yes or no) question that asked whether they would
be willing to pay a proposed amount for the treatment or intervention
being evaluated.
To assess the monetary value of a treatment that would eliminate
the risk of restenosis in the year after a PCI, each patient was asked
before their planned cardiac catheterization the following question:
If you undergo an angioplasty or stent procedure today,
there is a risk that the blockage in the artery will come back
in the next 6 to 12 months, a complication called restenosis,
which could lead to recurrent chest pains (or other symptoms). Restenosis does not put your life in danger but could

Willingness To Pay To Eliminate Restenosis

47

result in 1 or more revascularization procedure(s) in the

future. Those procedures could be another angioplasty,
implantation of a stent, or, in rare cases, coronary artery
bypass surgery. The risk of restenosis is around X%. Let us
suppose the existence of a new treatment that reduces this
risk to 0%. Would you be willing to pay $Y for this new and
improved treatment? 1) Yes 2) No.
Each patient was randomly assigned a single price (Y) of $500,
$1000, $1500, $2000, $2500, or $3000. The price range was decided
based on current incremental cost of DES compared to BMS, which
was between $1500 and $2000 in most Canadian hospitals. The
investigators explained to the patients that in order to obtain this new
treatment, they would be required to pay out of pocket the proposed
amount before the intervention. To test whether WTP would increase
with the magnitude in baseline risk, patients were randomly assigned
to 1 of 2 alternative risks of restenosis (X): 10% or 20%. The
combination of 6 different prices and 2 baseline risk values resulted
in 12 alternative scenarios distributed with equal probabilities among
the patients. To mitigate the hypothetical bias, the fact that some
patients are willing to say yes within a hypothetical context but are
unwilling when presented with a real context, we added a second
WTP question in order to validate the response to the first question.9
If the patient answered yes to the proposed bid, the amount was
increased by $500, and the patient was asked again whether he or she
would be still be willing to pay. In the event that patients refused to
answer the WTP scenario questions or gave an I dont know
response, they were considered to reject the proposed amount (ie,
were assigned the no response). Although no consensus exists,
Blumenschein et al9 suggested adding an are you sure question as
a means to validate the patients answer. Adding a second WTP was
believed to increase patients reflection time on the initial question
by focusing on the economic value of avoiding restenosis. The
lowest proposed amount ($500) was selected because it was representative of the selected range of bids while remaining a marginal
increase compared to initial proposed amounts.

QOL Assessment
To assess a possible relationship between QOL and WTP, patients
also were asked to provide mental health status information using the
Symptom Checklist-90-R (SCL-90-R)14 and QOL information using
the 36-item Medical Outcome Study Short-Form Health Survey
(SF-36) questionnaire.15

Statistical Analyses
Continuous variables are described as meanSD and categorical
variables by frequencies. Nonnormally distributed continuous variables were compared with the Wilcoxon rank sum test.
To estimate the median WTP, we used the nonparametric method
proposed by Kristrom.16 Assuming that the probabilities of WTP
corresponding to each bid increase monotonically with decreasing
price, a linear interpolation should provide a reasonably accurate
approximation to the true relationship. Thus, the median WTP can be
estimated as the bid at which the probability of a positive response,
estimated from the linear model, is 50%. If the observed proportions
of positive responses did not follow a monotone curve, this was
interpreted as due to sampling error or too-small increases between
the adjacent bids. In that case, the probabilities were recalculated by
combining the adjacent bids until all the probabilities followed a
monotone sequence, and the median was reestimated using the
combined bids.
The responses to the WTP question were assessed by 2 approaches. In the first approach, only the first amount assigned was
considered. The second, more conservative approach was used to
avoid overestimation of the true WTP.17 In that approach, a patient
was considered as willing to pay the first amount only if he or she
also agreed to pay $500 more than the originally assigned price. This
second amount was not used when estimating the median WTP.
We used multiple logistic regression to identify patient characteristics independently associated with a higher probability of respond-

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Circ Cardiovasc Qual Outcomes

January 2011

ing by the affirmative to the WTP question. Separate analyses were

performed for each of the 2 approaches discussed previously. Price,
risk of restenosis, patient income, history of PCI, history of myocardial infarction (MI), and history of coronary arterial bypass graft
(CABG) surgery were hypothesized a priori to influence the patients
answers to the WTP question and, therefore, were forced into the
model regardless of their statistical significance. We then used
forward and backward model selection procedures in separate
analyses to identify additional statistically significant (P0.05)
determinants of the responses to the WTP question among the
following variables: age, sex, education, working status, chronic
heart failure, history of MI, history of CABG surgery, somatization
score, depression score, anxiety score, SF-36 mental component
score (MCS), and SF-36 physical component score (PCS).
To investigate how increasing price affects the patients responses
to the WTP questions, we considered 4 alternative models for the
effect of price. All 4 models adjusted for the same a priori-selected
covariates but represented the effect of price differently. Specifically,
the models represented the effect of price using the following
functions: linear (model 1), logarithmic (model 2), 2-term quadratic
function with separate linear and quadratic terms (model 3), and
restricted 1-term quadratic function without the linear term (model
4). In the quadratic models, original prices were transformed to price
increment, calculated as price$500 (ie, centered to have 0 value at
the minimum price of $500 considered in our study). In model 3, we
tested the quadratic component for the nonlinearity of the effect of
price. Model 4 restricts the estimated quadratic function to have the
maximum value at a price of $500, which ensures a monotonically
decreasing effect of price. In contrast, model 3 may yield a
nonmonotone effect of price, which would be considered clinically
implausible and likely to reflect overfitting. In addition, we tested the
significance of the linear term in model 3. The lack of significance
of the linear term (P0.05) was interpreted as the evidence that the
monotone effect of price, estimated in model 4, provided equally
good fit to data as the more complex, and possibly nonmonotone,
function estimated in model 3. We then used the Akaike information
criterion (AIC),18 which accounts for the difference in each models
degrees of freedom, to determine the best fitting among the 4
alternative models.
A 2-tailed P0.05 for the Wald test was considered statistically
significant for all tests. Analyses were performed using SAS version
9.1.3 (SAS Institute; Cary, NC) statistical software.

Results
Patient Sample

Table 1. Demographic Characteristics of the Study Population

Variable

Total

Age, y (meanSD)

64.110.9

Male sex

198 (73.3)

Marital status
Married or living as married

175 (65.5)

Divorced or separated

41 (15.4)

Widowed

25 (9.4)

Never married

26 (9.7)

Employment status
Employed
Retired or unemployed

91 (34.2)
175 (65.8)

Gross family annual income

$60 000 and missing
$60 000

213 (78.9)
57 (21.1)

Education level
Grade school

42 (15.6)

High school

121 (44.8)

College

52 (19.3)

University

55 (20.4)

Clinical characteristics
Stable angina and inducible ischemia
Diabetes

132 (49.8)
64 (23.9)

History of MI

104 (40.8)

History of PCI

76 (28.9)

History of CABG surgery

38 (14.2)

Data are presented as no. (%), unless otherwise indicated.

the percentage of patients who gave a positive response to the

WTP questions as a function of the price being asked.
Because 50% of the patients responded positively to the
$3000 price, we can assume that the median WTP amount,
using only the response to the first question, is at least $3000.
Based on linear extrapolation, the median WTP was esti-

A total of 312 patients were approached to participate in our

study. Of these, 270 (87%) completed both parts of the WTP
questionnaire and were included in our analysis. Three
patients gave protest answers (eg, patients refused to answer
the WTP question due to ideological convictions), and 7
patients responded with an I dont know answer; all were
assumed to have given a negative response to the WTP offer.
Socioeconomic and clinical characteristics of the study population are presented in Table 1.

Patient Perceptions on the Role of PCI

The majority of patients initially believed that PCI could
prolong their life span and improve their QOL (90.7% and
92.2%, respectively).

WTP
Most (68.9%) patients were willing to pay the amount
proposed in the first question. Among those who were willing
to pay the first amount, the majority (85.9%) also were
willing to pay $500 more. Therefore, 59.2% of study patients
were willing to pay both proposed amounts. Figure 1 shows

Figure 1. Percentage of patients positively responding to WTP

questions in relation to the amount asked. The solid curve
represents the proportion of patients positively responding to
the first WTP question only. The dashed curve represents the
linear extrapolation of the first scenario question. The f curve
represents the proportion of patients positively responding to
both the first and the second WTP question.

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Willingness To Pay To Eliminate Restenosis

49

Table 2. Patient QOL and Mental Health Status According to

WTP the Proposed Amount
Willing To Pay

Unwilling To Pay Mean

Anxiety

0.40 (0.100.60)

0.45 (0.100.60)

0.83

Depression

0.56 (0.150.77)

0.60 (0.150.85)

0.71

Somatization

0.77 (0.331.00)

0.82 (0.331.17)

0.75

MCS

51.33 (46.5958.32)

50.65 (45.6557.09)

0.41

PCS

38.24 (29.6746.84)

38.45 (30.4347.42)

0.82

SCL-90-R*

SF-36

Data are presented as mean (interquartile range).

*SCL-90-R score ranges from 0 to 4, where 4 is the worst possible score.
SF-36 score ranges from 0 to 100, where 100 is the best possible score.
Figure 2. Percentage of patients positively responding to the
WTP question as a function of the presented risk of restenosis
following PCI. Positive response to the WTP question is based
on the conservative approach assumption. The curve represents the percentage of patients positively responding to the
WTP question when presented with a 20% risk of restenosis
following PCI. The curve represents the percentage of
patients positively responding to the WTP question when presented with a 10% risk of restenosis following PCI.

QOL

mated to be as high as $3784. When using the second, more

conservative approach, based on the willingness to accept the
price $500 higher than the originally stated price, the median
WTP was estimated at $2802. When we reestimated the
median using all the original percentages of positive answers
to the WTP questions (without aggregation), we obtained the
value of $2806, which is very close to the median of $2802
(relative difference of 0.2%) calculated based on the combined bids.

Effect of Price on the Probability of a Positive

Response to the WTP Question

Scale Test
To test the construct validity of our study, we also examined
the probability of positively responding to the WTP question
as the function of the risk of restenosis (10% or 20%), which
could be defined as a scale test (Figure 2).19 We expected the
2 curves to show that the proportion of positive response
would be lower in the patients presented with the 10% risk of
restenosis scenario and that it would decrease when the
amounts asked increased. Although the 2 curves were generally consistent with these assumptions, they did not completely follow them (Figure 2). Because capacity to pay could
greatly influence the probability of positively responding to
the WTP, we hypothesized that these discrepancies may be
due to residual confounding by the differences in individual
patient income. Therefore, we conducted a multivariable
regression analysis to examine how the probability of being
willing to pay was related to the risk of restenosis (20%
versus 10%) after having adjusted for patients income and
the amount asked. Results of the multivariable analysis
indicated that among patients with the same income and
assigned the same price, those presented with a greater risk of
restenosis would be significantly more likely to respond
positively to the WTP question (odds ratio [OR], 1.78, 95%
CI, 1.07 to 2.97). These results tend to support the idea that

patients were indeed able to discriminate between the levels

of restenosis risk assumed in the 2 scenarios.

Mean scores of several dimensions of QOL assessed with the

SCL-90-R and SF-36 questionnaires are presented in Table 2.
Patients who were willing to pay had similar anxiety, depression, and somatization scores as assessed by the SCL-90-R
questionnaires as those who refused. The SF-36 MCS and
SF-36 PCS were also similar in patients who were and were
not willing to pay the proposed amount.

Among the 3 alternative models (see Statistical Analysis

section) that yielded clinically plausible, monotonically decreasing effects of price, the restricted quadratic model 4 fit
the data much better than the 2 other models (AIC, 300.9 for
model 4, 304.0 for model 1, and 307.3 for model 2). Model 4
fit was also marginally better than the implausible nonmonotone function estimated with the unrestricted 2-term quadratic
model 3 (AIC, 301.1). Moreover, in model 3, the linear term
was statistically nonsignificant (P0.18). The latter finding
corroborates our expectation that the highest probability of a
positive answer corresponds to a price, which is not significantly different from the minimum price of $500 considered
in our study and, thus, provides further support for the
clinically plausible model 4.

Predictors of a Positive Answer to the

WTP Question
Results of simple logistic regression analyses for predicting
the probability of being willing to pay the proposed amount
(conservative approach) are presented in Table 3. As expected, patients with a gross family income of $60 000 and
those assigned to a greater risk of restenosis in the following
year (20% versus 10%) were more likely to be willing to pay
the proposed amount. Using the restricted quadratic function,
corresponding to the best-fitting model (model 4) for the
effect of price, an increase in price was associated with a
significant decrease in patient WTP (P0.014).
Table 4 summarizes the results of the final multivariable
logistic regression model selected by both the forward and the
backward procedures. The model identified 2 variables as

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Table 3. Unadjusted Associations Between Several Variables

and WTP Based on a Positive Answer to Both Questions
(Second Approach)
Variable

$60 000; risk of restenosis 20%; and a history of PCI, MI,

and CABG surgery, the estimated probabilities of their
answering yes to the WTP question were 0.81, 0.80, and 0.77
for the original bids of $500, $1000, and $1500, respectively.
However, for the patients with the same characteristics, the
estimated probability decreased to 0.72 at $2000 and 0.64 at
$2500 and was as low as 0.53 for the maximum price of
$3000. None of the other sociodemographic variables or
clinical characteristics was independently associated with the
probability of being willing to pay the proposed amount
(Table 4).

Unadjusted OR

95% CI

Price asked in $1000*

...

...

0.014

Gross family income ($60 000 vs

$60 000 or missing)

1.89

1.013.55 0.05

Risk of restenosis in the following year

(20% vs 10%)

1.66

1.012.72 0.05

History of PCI

1.31

0.762.27 0.33

History of MI

1.00

0.601.67 1.00

History of a CABG surgery

0.97

0.481.94 0.93

Discussion

Age, y

0.99

0.961.01 0.22

Female vs male sex

0.85

0.491.46 0.55

College and higher vs lower

1.62

0.972.67 0.06

The respondent is currently employed

0.87

0.521.45 0.59

Somatization

0.85

0.561.30 0.46

Depression

0.87

0.561.37 0.55

Anxiety

0.78

0.461.32 0.35

SF-36 MCS

1.01

0.981.03 0.54

SF-36 PCS

1.00

0.981.02 0.88

Patients waiting for a coronary angiography with ad hoc PCI

would be willing to pay a median amount of $2802 for a
treatment that would eliminate their risk of restenosis following PCI. Considering that patients who refused to answer the
WTP question and those who responded with an I dont
know response were considered to reject the proposed
amount, the actual median WTP amount might be even
higher. As expected, higher income and lower prices favored
answering positively to the WTP question, upholding the
internal validity of the method we used.17 Although higher
prices were shown to decrease the patients probability of
positively responding to the WTP question, the relation
seemed to follow a quadratic relationship, mainly beyond
$1500. Such results seem to indicate that the ability to pay
(and not the price of the treatment eliminating the risk of
restenosis) would be the only parameter of importance at
prices below $1500. This finding could imply that patients
consider that such a therapy is worth at least $1500. Alternatively, this finding may indicate that patients do not
consider the budgetary impact of the increase as being
constant. For example, increasing the price from $500 to
$1000 may not have the same impact for patients as increasing the price from $2000 to $2500.
To the best of our knowledge, this study is the first to
estimate patients WTP for the elimination of a risk of
restenosis in a publicly funded healthcare system setting.
Greenberg et al20 previously reported that US patients were
willing to pay no more than $US 273 and $US 366 for a
similar 10% and 20% reduction of the risk of restenosis.
Several reasons may explain the differences in observed WTP
between both studies. First, both risk scenarios in our study
assessed patients WTP for the complete elimination of the
risk of restenosis. Although our observed median WTP is
much higher than those observed in the American study,
patients in the latter study were willing to pay a much higher
amount ($1162) for the complete elimination of the risk of
restenosis. Second, given that patient healthcare costs are
already covered by taxes in Canada, it is possible that patients
would be willing to pay a much higher out-of-pocket amount
because they are only directly paying for the treatment that
eliminates the risk of restenosis compared to US patients who
would be required to pay for the whole procedure as well as
the hypothetical treatment.
Our analysis does not refer to a specific technology aimed
at reducing the risk of restenosis, such as DES, but to a
hypothetical treatment that can completely eliminate resteno-

*Price asked (per $1000 increment) has a quadratic relation with patient
WTP (see text for details). Price asked was calculated as initial price$500 (ie,
centered to have 0 value at the minimum price of $500 considered in our
study).
Per 1-point increase.

independent, statistically significant predictors of the probability of answering positively to the WTP question (Table 4).
Patients with gross family income $60 000 were more than
twice as likely to respond positively to WTP questions than
those with a lower income (OR, 2.81; 95% CI, 1.32 to 5.97).
An increase in price was shown to have a significant
quadratic relation to patient response to the WTP question
(P0.001). In general, below $1500, price had little impact
on patient response to the WTP question. In contrast, as the
prices increased from $1500 to $3000, the probability of
positively responding to the WTP question started to decrease
sharply. For example, for patients with a gross family income
Table 4.

Independent Predictors of WTP

Independent Variable

OR*

95% CI

Price asked in $1000

...

...

Gross family income ($60 000 vs

$60 000 or missing)

2.81

1.325.97

0.01

Risk of restenosis in the following

year (20% vs 10%)

1.61

0.902.90

0.11

History of PCI

1.59

0.823.06

0.17

History of MI

0.87

0.481.59

0.65

History of a CABG surgery

1.34

0.553.28

0.52

0.001

*Adjusted for all other variables listed in the table.

Price asked (per $1000 increment) has a quadratic relation with patient
WTP (see text for details). Price asked was calculated as initial price$500 (ie,
centered to have 0 value at the minimum price of $500 considered in our
study).
Variable was forced into the model based on a priori consideration
regardless of its statistical significance.

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Guertin et al
sis. No treatment currently can achieve such a health benefit.
Most cost-effectiveness analyses have indicated that the best
bang for the buck with DES may be limited to patients with
higher risk profiles, although the widespread implantation of
DES in the unselected population may not be cost-effective.6,2123 Such evaluations usually were based on a diseasespecific cost-effectiveness ratio: cost per RR avoided.2125
Although this metric has intuitive appeal and is straightforward to calculate, the proper threshold value to declare that an
intervention is cost-effective was derived from available
literature and believed to be $10 000 per RR avoided.20 22
Compared with societal thresholds in cost-effectiveness analyses, the amount patients are willing to pay to attain a
preferred health state may substantially differ from societys
WTP for the same outcome. Therefore, our results should not
be used to set a threshold to declare a treatment as costeffective when using the cost per RR avoided metric. We can
only conclude that patients would be willing to pay a
substantial amount ($2802 out of their pocket), which
amounts to close to 3 times the incremental cost of a DES
over a BMS (currently $1000), for a treatment that completely abolishes the risk of this detrimental health condition
(a goal that has yet to be realized with current therapies).
Our study has limitations that we need to acknowledge.
First, our selected range of value underestimated patients
WTP for the intervention, and as such, we needed to linearly
extrapolate our populations median WTP. Although the
selected range was based on the incremental cost of DES over
BMS, a wider or higher range of bids would have yielded a
more-precise answer. Additionally, WTP using an out-ofpocket amount already has been shown to overestimate
patients real WTP.9 Despite attempting to palliate this issue,
patients may still have stated an increased WTP due to the
virtual exercise of the survey. Second, we used an ex post
approach that involved asking a sample population of patients
undergoing cardiac catheterization with ad hoc PCI about
their WTP for a treatment that would eliminate the risk of
restenosis. The ex post approach estimates the amount a user
would be willing to pay for the treatment at the point of
consumption.11 In contrast, the ex ante approach estimates the
amount an individual would be willing to pay, through
increased taxes or insurances fees, for the treatment to be
covered by an insurance plan.11 Although the ex post approach is more commonly used in contingent valuations,
some have argued that the ex ante approach should be favored
due to its theoretical foundation.26 However, the ex post
approach offers several advantages, including better understanding by actual patients of risk and benefits associated
with the proposed treatment.27,28 Third, we used a closedended format to elicit our patients WTP. Evidence shows
that different formats can yield different estimates of WTP;
however, there is no consensus on which format should be
used.12 There is at least some concern that closed-ended
formats can overestimate the real WTP.29,30 Fourth, our study
was performed in a single large teaching hospital. Although
this center provides services to patients in and beyond the
greater Montreal region, our study sample comprised essentially French-Canadians whose values may possibly differ
from patients outside our province or country. Finally, as

Willingness To Pay To Eliminate Restenosis

51

acknowledged earlier, we attempted to assess patients WTP

for a hypothetical treatment that would completely eliminate
restenosis with no additional risk. This assumption diverges
from the current outcome of DES, which remains limited by
a residual risk of restenosis, although the residual risk appears
lower than 5% to 7% in most cases.5 Therefore, the WTP we
assessed cannot be considered equivalent to the WTP for the
incremental cost of DES versus BMS, and determining such
a WTP would require an additional contingent valuation
specifically comparing the benefits of DES to BMS. Furthermore, conventional decision theory would suggest that the
probability of a positive answer to the WTP question should
be proportional to the baseline risk.31,32 Accordingly, in our
study, the group presented with the 20% risk of restenosis
should have a twice-higher probability of a positive answer
than the 10% group. Our point estimate of the adjusted OR
for the higher (20%) versus lower (10%) baseline risk (OR,
1.78; 95% CI, 1.07 to 2.97) is slightly below the expected
value of 2.0, but the latter value is well within the estimated
95% CI, suggesting that the discrepancy may be due to
sampling error. Whereas our questionnaire was designed to
assess WTP for only a 10% or 20% risk of restenosis, it
would be interesting to estimate the WTP corresponding to
other risk levels. Finally, it is possible that the actual increase
in the probability of the patient willing to pay in the situation
with the higher baseline risk of restenosis is lower than
expected because of concerns about the incremental risk of
other associated complications.
In conclusion, despite being informed that restenosis is a
non-life-threatening condition, our results indicate that patients would be willing to pay a substantial amount to
eliminate the risk of this complication after PCI. Although
our results provide additional information on the benefits
provided by technologies that reduce restenosis rates, a
complete cost-benefit analysis specifically examining DES
would be required to assess the entire benefits provided by
DES over BMS.

Sources of Funding
This study was funded by the Fonds de la recherche en Sante du
Quebec (FRSQ). Drs Rinfret and Brophy are clinician-scientists of
the FRSQ. Dr Abrahamowicz is a James McGill Professor of
Biostatistics at McGill University.

Disclosures
Dr Cohen has received grant support from Cordis and Boston
Scientific and consulting fees from Medtronic. Dr Rinfret has
received grant support from Cordis Canada and consulting fees from
Cordis and Abbott Vascular Canada. No other potential conflict of
interest relevant to this article was reported.

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