title: A cost-efficacy decision analysis of prophylactic clip placement after endoscopic removal of large polyps.
abstract: OBJECTIVE
  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.
authors: Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address: n-parikh@fsm.northwestern.edu.
authors: Neehar D
authors: ND
authors: Parikh
authors: Kyle
authors: K
authors: Zanocco
authors: Rajesh N
authors: RN
authors: Keswani
authors: Andrew J
authors: AJ
authors: Gawron
mesh_terms: D003113:Colonoscopy / Q000009:adverse effects*; D004724:Endoscopy / Q000009:adverse effects*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology*; D006801:Humans; D007417:Intestinal Polyps / Q000601:surgery*; D008297:Male; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011183:Postoperative Complications / Q000453:epidemiology*; D011725:Pyridines / Q000627:therapeutic use*
chemical_list: D010975:Platelet Aggregation Inhibitors; D011725:Pyridines; C446540:thienopyridine
keywords: Endoclip; ICER; QALY; Resection; incremental cost-effectiveness ratio
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