title: Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions.
abstract: OBJECTIVE
  Large laterally spreading lesions (LSL) in the colon and rectum can be safely and effectively removed by endoscopic mucosal resection (EMR). However, many patients still undergo surgery. Endoscopic treatment may be more cost effective. We compared the costs of endoscopic versus surgical management of large LSL.
  
  
  METHODS
  We performed a prospective, observational, multicenter study of consecutive patients referred to 1 of 7 academic hospitals in Australia for the management of large LSL (≥ 20 mm) from January 2010 to December 2013. We collected data on numbers of patients undergoing EMR, actual endoscopic management costs (index colonoscopy, hospital stay, adverse events, and first surveillance colonoscopy), characteristics of patients and lesions, outcomes, and adverse events, and findings from follow-up examinations 14 days, 4-6 months, and 16-18 months after treatment. We compared data from patients who underwent EMR with those from a model in which all patients underwent surgery without any complications. Event-specific costs, based on Australian refined diagnosis-related group codes, were used to estimate average cost per patient.
  
  
  RESULTS
  EMR was performed on 1489 lesions (mean size, 36 mm) in 1353 patients (mean age, 67 years; 52.1% male). Total costs involved in the endoscopic management of large LSL were US $6,316,593 and total inpatient hospitalization length of stay was 1180 days. The total cost predicted for the surgical management group was US $16,601,502, with a total inpatient hospitalization length of stay of 4986 days. Endoscopic management produced a potential total cost saving of US $10,284,909; the mean cost difference per patient was US $7602 (95% confidence interval, $8458-$9220; P < .001). Inpatient hospitalization length of stay was reduced by 2.81 nights per patient (95% confidence interval, 2.69-2.94; P < .001).
  
  
  CONCLUSIONS
  In a large multicenter study, endoscopic management of large LSL by EMR was significantly more cost-effective than surgery. Endoscopic management by EMR at an appropriately experienced and resourced tertiary center should be considered the first line of therapy for most patients with this disorder. This approach is likely to deliver substantial overall health expenditure savings. ClinicalTrials.gov, Number: NCT01368289.
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Jayanna
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Sydney, Australia.
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Burgess
authors.affiliation: Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, Australia.
authors.forename: Rajvinder
authors.initials: R
authors.lastname: Singh
authors.affiliation: Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia; Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Australia.
authors.forename: Luke F
authors.initials: LF
authors.lastname: Hourigan
authors.affiliation: Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Australia.
authors.forename: Gregor J
authors.initials: GJ
authors.lastname: Brown
authors.affiliation: Department of Endoscopic Services, Western Health, Melbourne, Australia.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Zanati
authors.affiliation: Department of Endoscopic Services, Western Health, Melbourne, Australia; University of Melbourne, Victoria, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Moss
authors.affiliation: Department of Colorectal Surgery, Monash Health, Dandenong, Australia.
authors.forename: James
authors.initials: J
authors.lastname: Lim
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Sonson
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Williams
authors.affiliation: Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Sydney, Australia. Electronic address: michael@citywestgastro.com.au.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Bourke
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D001315:Australia; D003106:Colon / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000601:surgery*; D003365:Costs and Cost Analysis; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012007:Rectum / Q000601:surgery*; D013514:Surgical Procedures, Operative / Q000191:economics* / Q000379:methods*
keywords: AR-DRG; Colorectal Surgery; Large Laterally Spreading Lesions; The Australian Colonic Endoscopic Resection (ACE) study