Cost analysis for complex colon polyps

Wani_headshot Ryan Law, DO¹ and Sachin Wani, MD² discuss their article “Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis.”

We performed a cost-effectiveness analysis comparing laparoscopic and endoscopic resection strategies in patients with complex colon polyps and sought to identify predictors that determine cost-effectiveness. Mounting evidence from observational studies suggests that complex colon polyps can be safely and effectively removed with endoscopic resection. While endoscopic resection is generally considered the preferred treatment modality for complex colon polyps, many patients are still referred for surgical resection for a variety of cited reasons (ie, perceived lack of procedural safety with endoscopic resection, incomplete polyp resection, adenoma recurrence following endoscopic resection).

Recent published data suggest that surgical resection for colon polyps can be associated with a high morbidity rate (adverse event rate of 17% in one series). While both resection strategies are clearly effective, there is a paucity of data on the cost effectiveness of each modality. In addition, predictors that determine cost-effectiveness for these 2 competing strategies have not been defined. Wani_fig

Figure 1. Hybrid model of the linear decision tree terminating in Markov models. Two strategies are compared, endoscopic resection (ER) and laparoscopic resection (LR). In this decision tree a square node means the decision node at entry, filled circles are chance nodes, and the circles inset with “M” represent the Markov nodes.

Our results demonstrate that laparoscopic resection is more costly and yielded less quality adjusted life years (QALYs) in comparison to endoscopic resection. The costs associated with endoscopic resection of a complex colon polyp were $5,570 per patient and yielded 9.64 QALYs, while laparoscopic resection to treat a similar polyp cost $18,717 per patient while yielding fewer QALYs of 9.577. Thus there was an incremental cost of $13,147 per patient under the laparoscopic strategy. One way sensitivity analyses determined that our model was most sensitive to age, technical success (75.8%) and adverse event rates (>12%), and costs of laparoscopic resection ($14,000).

Our findings clearly demonstrate that endoscopic resection is a more cost effective strategy for the management of complex colon polyps. A recently published study from the Australian Colonic Endoscopic Resection study group reported similar findings. This study also demonstrated a cost savings of >$7500 US dollars per patient when an endoscopic resection strategy was employed. Given these results along with the efficacy of endoscopic resection, we believe that laparoscopic resection should be reserved for complex colon polyps with characteristics concerning for submucosally invasive cancer, those polyps likely to result in an incomplete resection, or recalcitrant/recurrent polyps after 1year of attempted endoscopic resection.

The objective thresholds described in this study for technical success and adverse event rate could serve as potential quality metrics for endoscopists performing endoscopic resection in clinical practice. Providers not meeting these quality benchmarks should strongly consider referral to an expert center/endoscopist for initial resection as failed endoscopic resection attempts make future attempts at endoscopic resection challenging. In the absence of any evidence of invasive cancer, referral to an expert center/endoscopist for management of large complex colon polyps should be considered prior to surgical referral for laparoscopic resection.

Affiliations:
¹Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois and the Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
²Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA

Read the abstract for this article here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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