Factors involved in endoscopists’ choice for prophylactic clipping after colorectal endoscopic mucosal resection: a discrete choice experiment

Abstract

Background: Delayed bleeding (DB) occurs in $10% after colorectal EMR. Prophylactic clipping (PC) was reported to significantly decrease DB-rate in proximal lesions !2 cm. Objective: Our aim was to determine which predefined variables contribute to using PC in clinical practice. Methods: We performed an international discrete choice experiment (DCE) among $500 endoscopists. Relevant variables for PC use were selected by EMR experts: previous DB, anticoagulants, polyp size, morphology, location, intraprocedural bleeding and visible vessel(s). Respondents answered case scenarios with various variable combinations, each time choosing only one scenario for PC, or the 'none' option. Part-worth utilities and importance weights were calculated using HB regression. Subsequently, a predictive model was created to calculate the likelihood of endoscopists choosing PC in any given case. Results: The survey was completed by 190 EMR endoscopists from 17 countries. In total, 8% would never use PC, whereas 30.9% never chose the 'none' option. All variables except polyp type were significant in decision-making for PC (p < .01). The most important factor was anticoagulant use, accounting for 22.5% in decision-making. Polyps <2 cm were considered eligible for PC by 14% in the presence of high-weighing factors such as anticoagulant use. No significant differences were found between high and low-to-moderately experienced endoscopists. Conclusions: PC after EMR is often considered useful by endoscopists, usually based on risk factors for DB. Anticoagulant use was the most important factor in decision-making for PC, independent of endoscopist experience. Although not considered cost-effective, one in seven endoscopists chose PC for adenomas <2 cm.

The Role of Clips in Preventing Delayed Bleeding After Colorectal Polyp Resection: An Individual Patient Data Meta-Analysis

“…This finding is in contrast with daily clinical practice, with studies showing that the routine use of antithrombotics is the most important decision factor for endoscopists to use prophylactic clips. 18,36 Our study has some limitations. Not all authors that were approached shared patient data for varying reasons.…”

“…9,10,13 Nonetheless, it has been reported that the use of antithrombotics is the most important decision factor for endoscopists to use prophylactic clips in daily clinical practice. 18,19 To reach consensus about the patient groups that may benefit from prophylactic clipping, a detailed and robust analysis of the available data is important. Although a meta-analysis of aggregated data is limited by reporting issues and sample size of the individual studies, an individual patient data meta-analysis (IPDMA) may offer a solution by collecting raw data from the included studies and combining these into 1 large dataset.…”

Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

“…Regarding accessories, in clinical practice prophylactic clipping of polyp resection defects does not always adhere to current recommendations and its overuse should be discouraged [69]. In this sense, determining the average need of accessories per procedure and periodically revisiting the number of accessories used could help to reduce waste and gain efficiency.…”