title: Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis.
abstract: OBJECTIVE
  Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP.
  
  
  METHODS
  A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges.
  
  
  RESULTS
  LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000.
  
  
  CONCLUSIONS
  Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.
authors.affiliation: Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Law
authors.affiliation: Arizona Digestive Health, Gilbert, Arizona, USA.
authors.forename: Ananya
authors.initials: A
authors.lastname: Das
authors.affiliation: Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
authors.forename: Dyanna
authors.initials: D
authors.lastname: Gregory
authors.affiliation: Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
authors.forename: Srinadh
authors.initials: S
authors.lastname: Komanduri
authors.affiliation: Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA.
authors.forename: Raman
authors.initials: R
authors.lastname: Muthusamy
authors.affiliation: Division of Gastroenterology, The University of Kansas Hospital, Kansas City, Kansas, USA.
authors.forename: Amit
authors.initials: A
authors.lastname: Rastogi
authors.affiliation: Digestive Diseases Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: John
authors.initials: J
authors.lastname: Vargo
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic-Jacksonville, Jacksonville, Florida, USA.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Wallace
authors.affiliation: Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
authors.forename: G S
authors.initials: GS
authors.lastname: Raju
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Rawad
authors.initials: R
authors.lastname: Mounzer
authors.affiliation: Gastrointestinal Oncology Department, Moffitt Cancer Center, Tampa, Florida, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Klapman
authors.affiliation: Department of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA.
authors.forename: Janak
authors.initials: J
authors.lastname: Shah
authors.affiliation: Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA.
authors.forename: Rabindra
authors.initials: R
authors.lastname: Watson
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Wilson
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Edmundowicz
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
authors.forename: Sachin
authors.initials: S
authors.lastname: Wani
mesh_terms: D000236:Adenoma / Q000191:economics / Q000601:surgery*; D003111:Colonic Polyps / Q000191:economics / Q000601:surgery*; D003113:Colonoscopy / Q000191:economics / Q000379:methods; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D000069916:Endoscopic Mucosal Resection / Q000191:economics / Q000379:methods*; D017048:Health Care Costs; D006801:Humans; D010535:Laparoscopy / Q000191:economics / Q000379:methods*; D008390:Markov Chains; D009364:Neoplasm Recurrence, Local / Q000191:economics / Q000453:epidemiology*; D019057:Quality-Adjusted Life Years; D014481:United States