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.
