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.
