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Mapping of coronary stent demand of several hospitals in Indonesia and its

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 2013 International Conference on Instrumentation, Communication, Information Technology and Biomedical Engineering
November 7th-8th, 2013, Bandung, Indonesia

Mapping of Coronary Stent Demand of Several

Hospitals in Indonesia and Its Forecasting
Alva Edy Tontowi1, Putri Ikra2 and Widowati Siswomihardjo3
1
Department of Mechanical and Industrial Engineering UniversitasGadjahMada, Indonesia.
(Tel. +62 274521673; Email: alvaedytontowi@ugm.ac.id)
2
Department of Mechanical and Industrial Engineering UniversitasGadjahMada, Indonesia.
(Tel. +62 274521673; Email: putri.ikra@gmail.com)
3
Faculty of Dentistry UniversitasGadjahMada, Indonesia.
(Tel. +62 274 515307; Email: bundi.kunto@gmail.com)

Abstract-Indonesia with 240s million population is counted as a
large population country. It is about 10% of that population is
elderly with potential having cardiovascular problem. An
alternative treatment to the people having that disease is by
implanting a coronary stent either BMS (Bare Metal Stent) or
DES (Drug Eluting Stent) types. Although, stent has been
accepted as an alternative technique to treat cardiovascular
patient, demand on stent seems to be high and growing fast.
However, there was no official published document showing the
demand on stent yet and so it was no available forecasting data.
This paper presents the map of stent demand and its forecast in a
period of time. Three hospitals in Java island have been observed
to collect data and these data were used to forecast its future
demand using double exponential smoothing with MAPE for
measuring its error of forecasting.
Keyword:stent, hospital, forecast, bare metal, drug eluting.
I. INTRODUCTION
It has been almost 25 years since intra vascular stent was
introduced for the first time to the public by trio inventors of
the patent: Palmaz, Schatz and Romano in 1988 [1], stenting is
becoming the best alternative treatment for vascular blood
blockage. This acceptance technique is attributed by minimally
invasive technique, opposing to the bypass surgery that is
carried out whenever stenting is not possible to be done.
Despite the stent has successful in solving the narrowing a
vascular vessel due to the plague, clinical investigations show
that stent design and geometry affect the post-implantation
restenosis [2]. Restenosis is known as a narrowing of a blood
vessel, leading to restricted blood flow [3]. In Indonesia itself,
several hospitals have used stent to treat patients who have
problem in vascular vessel blockage. Both types of stent
include bare metal stent type (BMS) and Drug Eluting Stent
(DES) with various materials and brands. Materials such as
stainless steel 316L, nitinol (nickel-titanium alloy), tantalum
and cobalt chromium (co-cr) have been used as stent materials
[4] that available in market. Among these materials, stainless
steel 316L was the most favorable material for BMS. Along
with the use of stent, most selection of stent that will be
implanted to the patient depends on the doctor. One important
consideration by the doctor is ease of delivery and restenosis.
However, this decision will be taking a risk as the doctor needs
to try first to the patient and no guarantee it will be successful
or not. Furthermore, doctor also faces difficulty and takes cost
if the doctor needs to try one by one while there are many stent
design and geometric commercially in market. In Indonesia
itself, the demand on stent looks like to be high and it is
growing rapidly year by year. However, currently there is no
official document available found on the stent demand and its
forecast for the future need. It is predicted that more than 10
brands are operating in Indonesia market and might be the
number of brand will increase in the few years to come
following the implementation of SJSK
(SistemJaminanSosialKesehatan) by BPJS
(BadanPenyelenggaraJaminanSosial) starting on January 1st,
2014. The aims of this work therefore to develop a preliminary
map of stent demand in several hospitals in Indonesia and to
forecast the future of demand based on the existing demand
gathered from those hospitals.
II. METHODS
Mapping and forecasting of stent demand would be carried out
at three prominent hospitals who have facility for Percutaneous
Coronary Intervention (PCI) including Harapan Kita Hospital
in Jakarta, Sardjito Hospital in Yogyakarta and Soetomo
Hospital in Surabaya. Mapping was done by gathering number
of stent (both types of BMS and DES) implanted at each
hospital for the period of 2-3 years. It was then plotted into pie
chart and histogram. The pie chart was used to show the market
share of each brand or type and histogram was applied to
exhibit number of implanted stent of each year. In forecasting
the stent demand, a double exponential smoothing method has
been applied. This method [5-7] was taken place by smoothing
the single exponential result and giving it the weight that its
values are going down exponentially. In this method, level and
trend need to be calculated first before forecasting in certain
period of time in equation-3. The level can be estimated by
following equation-1 and the trend may be estimated by
employing equation-2.
Lt = αYt + (1-α)(Lt-1 + Tt-1) (1)
Tt = β (Lt – Lt-1) + (1-β) Tt-1 (2)
Ỹt+p= Lt +p Tt (3)
 2013 Intternational Confference on Instrrumentation, Co
ommunication, In
nformation Tech
hnology and Bioomedical Engineeering
Novembe er 7th-8th, 2013,, Bandung, Indo
onesia

wherre Lt is the new n value off smoothing (present

( estim
mation Ass seen in Figgure 1 that am mong the braands of implaanted
level), α is smoothhing constant (0 < α < 1), Yt is actual vaalue in BMS S stent in Haarapan Kita hospital, Amazzonia Croco Stent
the tth period, β iss smoothing coonstant for treend estimationn (0 < with 34% has dom minated the shhare; while forr DES as show
wn in
β < 1), Tt is treend estimationn, P is the period
p that will
w be Figurre 2, there was
w only 19% % domination n brand belonng to
foreccasted and Ỹt+p is forecastting in the pthh period. To check Xiennce V. In the forecasting rresult, howeveer, both BMS S and
weatther the forecaasting result is closed to thee actual data, Mean DES exhibited sim milar trend too the actual with
w the MAP PE of
Absoolute Percentaage Error (MA APE) has beeen applied. Errror is 0.1044 and 0.132 respectively. Here, in term m of the erroor of
calcuulated by calculating the mean value of absolute error itsforrecasting, the BMS shows better forecasst compared to t the
perccentage. The lowest the MA APE, the betteer the forecastt. The DES.
MAP PE can be dettermined by eqquation-4 beloow.

1 N
Yt  Yˆt
MAPE 
N
t 1 Yt
(4)

w
whereN is the number
n of dataa.

III. RESSULTS AND DISSCUSSION

Results of thesse works are presented intto two thingss. The

first is in the form
m of map that showing a steent demand inn three
hosppitals with varrious brands and
a types (BM MS and DES)); and
the second is a forecasting
f off demand in a certain periiod of
timee.
Amazzonia Croco Stent

4% 2% 1% Apolo
o
% Fiigure 3. Actuaal and forcastiing of BMS deemand in Haraapan
5% 0% RX Multilink
M 8
Kita Hospitall based on datta in 2012(=00.99; =0.01;
8% Gazeelle
MAPE= =0.104)
34% Tango
7
7% Avan
nt

RX Mini
M Vision/RX
Vision
Tsunami
1
11% Chrono Cobalt
8% 2%
12
8% Musttang

Coroflex Blue

RX Ultra

Figure 1. Nuumber of implaanted Bare Meetal Stent (BM

MS)
innHarapan Kita Hospital in 2012
2

Xience V
1% Firebird
5% 3% 1% 1% Biomatrix

6% Biomime
19% Partner Fig
gure 4. Actuall and forcastinng of DES dem
mand in Harappan
8%
15% Taxcor II =0.66; =0.01;;
Kita Hospitall based on dataa in 2012 (=
Nobori MAPE= =0.132)
Endeavor

1
10% Cre‐8

Promus
Folloowing the 121 months oobservation, the demandd on
9% 14% BMS S as shown in Figure 3 tends to go o down and it is
8% Amazonia Pax

Janus preddicted continuue to decreasse for the nex

xt three monnths a
Coroflex Please
headd. For the same periood of time observationn, as
Figure 2. Num
mber of implaanted Drug Eluuting Stent (D
DES) illusttrated in Figure 4, oppposite trend occurred too the
innHarapan Kita Hospital in 2012
2 DES S. The demannd of DES seeems to increease.
 2013 Intternational Confference on Instrrumentation, Co
ommunication, In
nformation Tech
hnology and Bioomedical Engineeering
Novembe er 7th-8th, 2013,, Bandung, Indo
onesia

Avant Grade
12% Coroflex Blue
Firebird
4%
4 1
19% Multilink Vision
1% Pressilion
31%
Rx Mini Vision
25%
RX Multilink
Tsunami
tango
0% 4% 3%
3 kaname
1% 0% pro kinetik cobaltt

Figure 5. Nuumber of implaanted Bare Meetal Stent (BM

MS)
inSardjito Hospital
H in 20112
Biometrix
Fig
gure 8. Actuall and forcastinng of DES dem
mand in Sardjito
1%
0% pital based onn data in 2012((=0.50; =0.07; MAPE=11.06)
Hosp
Coroflex Pleasse

28% 41% Cre‐8 By loooking at Haraapan Kita hosspital Jakarta, domination inn one
Nobori brandd is not clear and almost aall brands have the same chhance
Titan
to haave similar market
m share. Dominationbegin appear when w
we observed Sardjjito hospital YYogyakarta. Th here was a bigg gap
8% Xience Prime
of diifferences bettween one brand to other brands. How wever,
11% 1%
promus elemeent Haraapan Kita and a Sardjitohospitals haave demonsttrated
10%
% absorb increeasing demandd of DES and decreasing deemand of BMS S.
Figure 6. Num
mber of implaanted Drug Eluuting Stent (D
DES)
Coroflex
inSardjito Hospital
H in 20112 3 5% 0% 6%
3% %
Simiilar to Harapaan Kita hospiital in Jakartaa, the need off stent Gazelle

for both
b type at Sardjito Hosppital was also high, but it i was 22%
loweer number com mpared to thaat of Harapan Kita. It was about Mustang

700 stents have been implantted per year atSardjito hoospital

64
4% Apollo
Yoggyakarta. As seen in thee Figure 5 and a 6, for BMS,
B
dommination was holded
h w market share of
by Corroflex Blue with
tango
31%%. While for thet DES, Biom metrix holds the highest market
m
share in this hosspital. It wass about 41%. In forecastinng as
arthos piko
showwn in Figure 7 and 8, how wever, the trennd of forecasst was
also similar to thee actual one. For the samee period of moonths,
the forecast show wing the dem mand of DES tends to inccrease Figure 9. Num
mber of implaanted Bare Meetal Stent (BM
MS)
whillst BMS goes down. The forecasting of BMS indiicated inSoetomo HHospital in 201
12
betteer result withh MAPE of 0.49 0 compareed to that off DES
foreccasting with MAPE
M of 1.066.
%0% 1%
1% 2% 1%
Nobori
1% 1% 0%
Biomatrix
1%
17% Firebird

25% Endiavor
42%
resolute integgriti
promus elemeent

5% promus
3
3%
titan

Figure 7. Actuaal and forcastinng of BMS deemand in Sarddjito

Figure
F 10. Num
mber of implaanted Drug Elu
uting Stent (D
DES)
Hosspital based onn data in 20122(=0.57; =00.03; MAPE=0.49)
inSutomo H
Hospital in 2012
 2013 International Conference on Instrumentation, Communication, Information Technology and Biomedical Engineering
What is about Soetomo hospital?. Strong domination of one
brand is very clear. Apollo held 64% of market share. It was
almost double of market share of Coroflex Blue at Sardjito
hospital. While for DES at Soetomo hospital, it was only 42 %
market share hold by Promus Element.
In forecasting, similar trends was also happened at Soetomo
hospital for BMS and DES demand. Forecasting for both types
of stent exhibited the good result as indicated by MAPE for
BMS and DES were 0.75 and 0.32 respectively.
Figure 11. Actual and forcasting of BMS demand in
Soetomo Hospital based on data in 2012 (=0.43; =0.08;
MAPE=0.75)
Figure 12. Actual and forcasting of DES demand in Soetomo
Hospital based on data in 2012 (=0.62; =0.02; MAPE=0.32)
Learning from those map and forecasting results of those three
prominent hospitals, these results still would be useful to figure
out an initial mapping of stent demand in Indonesia, although
those three hospitals can not be judged as a representative of
Indonesia hospital since there are 15 hospitals who have PCI
facility and eligible to treat cardiovascular problem [8]. Each
year, the need of stent increases where in 2012 itself about
nearly 4000 stents of BMS and DES have been implanted at
three hospitals. Suppose each hospital within 12 other hospitals
implants 100 stents in the same year, there will be 4000 plus
View publication stats
November 7th-8th, 2013, Bandung, Indonesia
1300 stents or 5300 stents are needed in Indonesia. So,
whenever SJSK that will be effectively implemented in January
2014 ahead, Indonesia government need to prepare spending
for those stents. Currently, there are about 10% of Indonesia
population elderly and waiting for this service insurance and
this elder population increases year by year.
IV. CONCLUSIONS
Mapping and forecasting have been carried out successfully
based on data gathering from three prominent hospitals in
Indonesia i.e. Harapan Kita, Sardjito and Soetomo hospitals.
The demand on stent of BMS and DES at those three hospitals
in general tends to increase yearly. However, among those
hospitals observed, Harapan Kita hospital shows the highest
number of stent demand, followed by Sardjito and Soetomo
hospital exhibited the lowest number of demand. Surprisingly,
the demand of BMS goes down and DES even increases
although the price is almost double of that BMS. This may be
due to the treatment power of DES is better that of BMS. If
look at the brand, several brands were also not well distributed
at those three hospitals and even domination was also showing
differently. In the forecasting that carried out using double
exponential smoothing method and MAPE for error checking,
this method has demonstrated a significant result. The
forecasting results exhibited a similar trend to the actual data.
Although the results of mapping and forecasting were only
taken from three hospitals, these are still useful as an initial
stage to figure out the need of stent in Indonesia, particularly
whenever SJSK will be implemented in 2014 ahead. Another
beneficial is that these results can be used also as one
consideration in stent design.
ACKNOWLEDGMENT
This paper was part of the research on developing an
Indonesian stent funded by DGHE Department of Education
and Culture of Indonesia. For this, authors would like to thank
for.
REFERENCES
[1] Lemelson - MIT Program,Julio Palmaz, Inventor of the Week
Archivehttp://web.mit.edu/invent/iow/palmaz.html
[2] Teo, E.C., Yuan, Q. and Yeo, J.H., Design optimization of coronary stents
by FEM, Journal of American Society for Artificial Internal Organs
(ASAIO), 46(2), 2000,p.201.
[3] Chang, C.C. and Ong, E.T., Coronary Restenosis, ActaCardiol Sin, 21,
2005,pp. 177-89.
[4] Levesque, J., Dube, D. and Fiset, M., Materials and Properties of Coronary
Stent, Advanced Materials and Processes, 2004.
[5] Hanke, J.E. andWichern, D.W.,Business Forecasting, 8thEdition, Pearson
Prentice Hall, United States of America, 2005.
[6] Armstrong, J.S. and Green, K.C., Demand Forecasting: Evidence-based
Methods, Department of Econometrics and Business Statistic, Monash
University, Australia, 2005, pp. 1-18.
[7] Green, K.C. and Amstrong, J.S., Demand Forecasting: Evidence-Based
Methods, International Journal of Forecasting, 2012, pp.1-27.
[8] DepartementKesehatan RI, ProfilKesehatan Indonesia 2008, Jakarta, 2009.