Cost-Effectiveness of Cold vs. Hot EMR in Managing Large Non-Pedunculated Colorectal Polyps (≥ 20 mm)

Aims Historically, non-pedunculated colorectal polyps≥20 mm have been managed with hot Endoscopic Mucosal Resection (EMR) as it offers various benefits including prevention of acute bleeding, residual dysplastic tissue ablation capacity, and easier transection with the use of electrocautery. Even after recent developments like thermal ablation of margins post-EMR and the use of prophylactic clips to prevent bleeding, the possibility of adverse events including increased rates of delayed bleeding and perforation post-EMR continues to remain high. As per recent data, cold EMR is increasingly used to reduce serious adverse events like perforation and post-procedural bleeding. In this study, we aim to compare the financial impacts of two types of EMR using the cost-effectiveness analysis [1] [2] [3] [4].

Methods We conducted a cost-effectiveness analysis comparing Cold vs Hot EMR for the resection of large non-pedunculated colorectal polyps, using a decision tree model. The decision tree included two treatment choices with hot EMR being the baseline treatment. The cost of hospitalization, procedure, adverse event management, and surveillance colonoscopy was obtained through CPT codes from Medicare or average institutional reimbursement. Probabilities of recurrence and adverse events were obtained from published literature including meta-analysis and RCTs. Outcomes included Quality Adjusted Life Years(QALY), Incremental costs, and Net Monetary Benefit (NMB). For primary analysis, we assumed that hot EMR was followed by prophylactic clip closure. We performed a probabilistic sensitivity analysis to account for real-world uncertainties. Analysis was performed in TreeAge Pro Healthcare 2024.

Results We found that the average cost associated with Cold EMR was $4,478 compared to $5,161 for Hot EMR, leading to a differential cost of $684. Incremental effectiveness was found to be 0.01 QALY in favor of Cold EMR. Tornado analysis revealed that the probability of perforation after hot EMR was most sensitive followed by the cost of individual prophylactic clip. The probability of recurrence after Cold EMR remained at the bottom half of the sensitivity analysis indicating low sensitivity to overall cost difference. Reduction in the probability of perforation after hot EMR from a reported 2% to 1% results in a marginal cost reduction to around $350. Threshold analysis revealed that Cold EMR remains a dominant strategy until the recurrence rate is<46%, given everything else remained constant. Cold EMR was the optimal strategy for 91.29% and Hot EMR emerged as the optimal strategy for 8.71% in probabilistic sensitivity analysis.

Conclusions In conclusion, Cold EMR is a cost-effective strategy for the resection of large non-pedunculated colorectal polyps at a commonly accepted Willingness-To-Pay threshold of $100,000/QALY. Although Cold EMR is not a standard practice for large polyps≥20 mm it is becoming increasingly common and hence it is valuable to understand its cost-effectiveness.

Publication History

Article published online:
27 March 2025

• References

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• 2 Ramai D, Clement B, Maida M. et al. Cold Endoscopic Mucosal Resection (c-EMR) of Nonpedunculated Colorectal Polyps≥20 mm: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58 (07): 661-667 Published 2024 Aug 1
• 3 Chandan S, Facciorusso A, Ramai D. et al. Snare tip soft coagulation (STSC) after endoscopic mucosal resection (EMR) of large (>  20 mm) non pedunculated colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2022; 10 (01): E74-E81 Published 2022 Jan 14
• 4 Search the physician fee Schedule | CMS. (n.d.) https://www.cms.gov/medicare/physician-fee-schedule/search