A cost-efficacy decision analysis of prophylactic clip placement after endoscopic removal of large polyps

Abstract

Background & 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 by using TreeAge Pro 2011 Software. 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- to 1.5-cm polyp removed during colonoscopy. We estimated postpolypectomy bleeding rates for patients receiving no medications, those with planned resumption of antiplatelet 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 postpolypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement.

Results: On the basis of the reference case, when patients did not receive anticoagulation therapy, clip placement was not cost-effective. However, for patients who did receive anticoagulation and antiplatelet 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 antiplatelet or anticoagulation therapy. This approach should be studied in a controlled trial.

Keywords: Endoclip; ICER; QALY; Resection; incremental cost-effectiveness ratio.

Fig. 1

Decision tree for prophylactic clip placement

Fig. 2

Sensitivity Analysis on Probability of Post-Polypectomy Bleed

Fig. 3

Two-Way Sensitivity Analysis of Reduction in Bleed Rate with Clip and Bleeding Rate

Fig. 4

Fig. 4a: Two-Way Sensitivity Analysis of Cost of GI Bleed and Bleeding Rate; Fig. 4b: Two-Way Sensitivity Analysis of Cost of Clip and Bleeding Rate; Fig. 4c: Two-Way Sensitivity Analysis on Number of Clips Placed and Bleeding Rate; Fig 4d: Two-Way Sensitivity Analysis of Utility Reduction for Hospitalization and Bleeding Rate; Fig. 4e: Two Way Sensitivity Analysis on Number of Clips Placed and Probability of harm from clip

Fig. 4

Fig. 4a: Two-Way Sensitivity Analysis of Cost of GI Bleed and Bleeding Rate; Fig. 4b: Two-Way Sensitivity Analysis of Cost of Clip and Bleeding Rate; Fig. 4c: Two-Way Sensitivity Analysis on Number of Clips Placed and Bleeding Rate; Fig 4d: Two-Way Sensitivity Analysis of Utility Reduction for Hospitalization and Bleeding Rate; Fig. 4e: Two Way Sensitivity Analysis on Number of Clips Placed and Probability of harm from clip

Fig. 4

Fig. 4a: Two-Way Sensitivity Analysis of Cost of GI Bleed and Bleeding Rate; Fig. 4b: Two-Way Sensitivity Analysis of Cost of Clip and Bleeding Rate; Fig. 4c: Two-Way Sensitivity Analysis on Number of Clips Placed and Bleeding Rate; Fig 4d: Two-Way Sensitivity Analysis of Utility Reduction for Hospitalization and Bleeding Rate; Fig. 4e: Two Way Sensitivity Analysis on Number of Clips Placed and Probability of harm from clip

Fig. 4

Fig. 4a: Two-Way Sensitivity Analysis of Cost of GI Bleed and Bleeding Rate; Fig. 4b: Two-Way Sensitivity Analysis of Cost of Clip and Bleeding Rate; Fig. 4c: Two-Way Sensitivity Analysis on Number of Clips Placed and Bleeding Rate; Fig 4d: Two-Way Sensitivity Analysis of Utility Reduction for Hospitalization and Bleeding Rate; Fig. 4e: Two Way Sensitivity Analysis on Number of Clips Placed and Probability of harm from clip

Fig. 4

Fig. 4a: Two-Way Sensitivity Analysis of Cost of GI Bleed and Bleeding Rate; Fig. 4b: Two-Way Sensitivity Analysis of Cost of Clip and Bleeding Rate; Fig. 4c: Two-Way Sensitivity Analysis on Number of Clips Placed and Bleeding Rate; Fig 4d: Two-Way Sensitivity Analysis of Utility Reduction for Hospitalization and Bleeding Rate; Fig. 4e: Two Way Sensitivity Analysis on Number of Clips Placed and Probability of harm from clip