A Cost-efficacy Decision Analysis of Prophylactic Clip Placement After Endoscopic Removal of Large Polyps

Abstract

Background and Aims Delayed bleeding after lower endoscopy and polypectomy can cause significant morbidity. One strategy to reduce bleeding is to place an endoscopic clip on the polypectomy site. We used decision analysis to investigate the cost effectiveness of routine clip placement after colon polypectomy. Methods Probabilities and plausible ranges were obtained from the literature, and a decision analysis was conducted using TreeAge Pro 2011 (TreeAge Software, Williamstown, MA). Our cost-effectiveness threshold was an incremental cost effectiveness ratio of $100,000 per quality adjusted life year. The reference case was a 50 year old patient who had a single 1.0–1.5 cm polyp removed during colonoscopy. We estimated post-polypectomy bleeding rates for patients receiving no medications, those with planned resumption of anti-platelet therapy (nonaspirin), or those receiving anticoagulation therapy after polypectomy. We performed several sensitivity analyses, varying the cost of a clip and hospitalization, number of clips placed, clip effectiveness in reducing post-polypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement. Results Based on the reference case, when patients did not receive anti-coagulation therapy, clip placement was not cost effective. However for patients who did receive anticoagulation and anti-platelet therapies, prophylactic clip placement was a cost-effective strategy. The cost-effectiveness of a prophylactic clip strategy was sensitive to the costs of clips and hospitalization, number of clips placed, and clip effectiveness. Conclusions Placement of a prophylactic endoscopic clip after polypectomy appears to be a cost-effective strategy for patients who receive anti-platelet or anticoagulation therapy. This approach should be studied in a controlled trial.

Postpolypectomy prophylactic clip closure for the prevention of delayed postpolypectomy bleeding: A systematic review

“…At current clip costs, the risk of DPPB would need to be at least 45% for prophylactic clip placement for there to be economic equilibrium. Similar findings were also seen in another study that used a decision tree model in a hypothetical reference case . Based on current costs of approximately $150 AUD per clip, routine prophylactic placement of any number of clips in the low‐risk case or placement of more than one prophylactic clip in patients receiving antiplatelets and anticoagulant therapy is not cost effective .…”

Outcome of EMR as an alternative to surgery in patients with complex colon polyps

“…3, 34-37 In our center, based on our animal experimental work and clinical experience, our technique of deep submucosal approximation of resection defects with clips, enables us to discharge patients, even those who reside far from the EMR center, soon after they recover without the need for hospitalization or a visit to a short-term hospital unit for observation, thereby reducing the cost of their care. 38-40 , 41 A recent randomized controlled study documented the benefits of clip closure after EMR. 42 Although endoscopists have debated the benefit of using clips for this purpose, we believe that deep approximation of a wound using clips correctly reduces postpolypectomy bleeding and overall cost of care.…”

Periprocedural management of aspirin during colonoscopy: a survey of practice patterns in the United States

“…In fact, a cost-effective analysis suggests that routine use of prophylactic clips may be cost-effective among patients who are receiving aspirin or anticoagulation therapy. 31 Currently, the use of prophylactic clips is anecdotal and not an evidence-based recommendation.…”