Mo1767 COLD EMR IS MORE COST-EFFECTIVE THAN HOT EMR FOR LARGE COLON POLYP RESECTION

Abstract

For large colorectal polyps, endoscopic mucosal resection without electrosurgical energy (“cold EMR”) is gaining popularity due to its safety advantages over traditional EMR (“hot EMR”). Because of the nearly-negligible risk of delayed hemorrhage and perforation, prophylactic clips are not used for cold EMR. In contrast, polyp recurrence rates are higher with cold EMR due to the lack of thermal energy and its tissue ablation effect. In light of these differences, we performed a cost-effectiveness analysis of these two techniques. We hypothesize that cold EMR will be less expensive and more effective. A decision analysis model was constructed, for resection of a 25 mm large colon polyp amenable to endoscopic removal. The decision tree incorporated EMR method, use of clips, procedural mortality, complications, treatment of complications (additional surgery, endoscopic procedure or hospital observation) as well as recurrence and treatment of recurrence (endoscopic polypectomy) (figure 1). Cost was calculated using the average national Medicare reimbursement in 2019 US dollars. Cost of the clips (not reimbursed by Medicare) was added. Quality of life was measured in terms of days of lost wages by the patient and the accompanying driver. Complication and recurrence rates were extracted from the existing literature, giving emphasis to recent systematic reviews and RCTs (table 1). Through one year of follow-up, the average cost of removing a large colon polyp by cold EMR was $3,046, as compared to $4,020 by hot EMR, attributing a cost advantage of $974 to cold EMR. Average days of lost wages was 4.1 days for the cold EMR strategy, which was less than 4.4 days for the hot EMR strategy. The cost advantage was driven by the lack of necessity of prophylactic clips in the cold EMR strategy. The analysis was sensitive to the cost of clips and the number of clips. Cold EMR is the "dominant" strategy over hot EMR, with less cost and better quality of life. The most impactful factor in the cost advantage of cold EMR was the lack of necessity of prophylactic clips. Our research lends further credence to the cold EMR technique as a safer and cheaper alternative to hot EMR. Adopting cold EMR as a primary resection strategy likely will result in significant cost savings over time, especially in specialized endoscopy units.View Large Image Figure ViewerDownload Hi-res image Download (PPT)