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In Reply: In response to Dr Beri, we excluded patients with prior revascularization because we were interested in studying the natural history of treating de novo disease, not the treatment of graft disease or a restenosis. We made no direct comparison of the outcomes of bare-metal stents vs drug-eluting stents because we believed such an analysis would be confounded. Bias could arise for 2 reasons. First, if patients with better unmeasured health are treated with drug-eluting stents, the apparent benefits of drug-eluting stents would be biased upward. Second, if higher-quality hospitals (for example, teaching hospitals) adopted drug-eluting stents more rapidly, the apparent benefits of drug-eluting stents would again be overstated.

Evidence for such bias is shown in the Figure, which displays 2-year rates of death or ST-elevation myocardial infarction (STEMI) month-by-month from February 2002 through December 2003 for patients receiving stents who met our inclusion criteria. Before the availability . . . [Full Text of this Article]

David J. Malenka, MD
david.malenka@hitchcock.org
Section of Cardiology
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire

Jonathan S. Skinner, PhD
Dartmouth Institute for Health Policy and Clinical Practice
Dartmouth College
Hanover, New Hampshire

F. Lee Lucas, PhD
Center for Outcomes Research and Evaluation
Maine Medical Center
Portland

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