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Cold versus hot endoscopic mucosal resection for large sessile colon polyps: A cost-effectiveness analysis.

BACKGROUND AND STUDY AIMS
For large sessile colorectal polyps (LSCPs), endoscopic mucosal resection without diathermy ("cold EMR") is gaining popularity due to its safety advantages over conventional EMR ("hot EMR"). Polyp recurrence rates have been reported to be higher with cold EMR. Considering these differences, we performed a cost-effectiveness analysis of these two techniques.


PATIENTS AND METHODS
A decision analysis model was constructed, for EMR of a LSCP. The decision tree incorporated EMR method, clip use, procedural mortality, adverse events and their management, and polyp recurrence. Quality of life was measured in terms of days of lost productivity. Adverse event and recurrence rates were extracted from the existing literature, giving emphasis to recent systematic reviews and RCTs.


RESULTS
Through 30 months of follow-up, the average cost of removing a LSCP cold EMR was $5,213, as compared to $6,168 by hot EMR, yielding a $955 USD cost difference (95% Confidence Interval (CI) $903-$1,006). Average days of lost productivity were 6.2 days for cold EMR and 6.3 days for hot EMR. This cost advantage remained over several analyses accounting for variations in recurrence rates and clip closure strategies. Clip cost and LSCP recurrence rate had the greatest, and least impact on marginal cost difference, respectively.


CONCLUSION
Cold EMR is the dominant strategy over hot EMR, with less cost and better quality of life. In theory, a complete transition to cold EMR for LSCPs in the US could result in an annual cost-savings approaching $7 million US dollars to Medicare beneficiaries.