Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions

doi:10.1016/j.cgh.2015.08.037

Clinical Gastroenterology and Hepatology

Volume 14, Issue 2, February 2016, Pages 271-278.e2

https://doi.org/10.1016/j.cgh.2015.08.037 Get rights and content

Background & Aims

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.

Section snippets

Study Design, Setting, and Patients

Consecutive patients referred to 1 of 7 Australian academic hospitals for the management of large LSL ≥20 mm were enrolled in this prospective observational study. The term laterally spreading tumor has traditionally been used to describe these lesions; however, using “tumor” as a descriptor implies the universal presence of submucosal invasion. This is misleading so we have avoided the use of this term. All lesions had been initially identified and referred by a nationally accredited

Patient and Lesion Characteristics

Between January 2010 and December 2013 EMR was performed on 1489 lesions in 1353 patients (mean age, 67 years; 52.1% male). American Society of Anaesthesiology scores were 1, 2, 3, and 4 in 642 (47.5%), 540 (39.9%), 158 (11.7%), and 5 (0.4%) patients, respectively. Mean lesion size was 37.3 mm (median, 30 mm; range, 20–180 mm; standard deviation [SD], 17.1 mm). A previous attempt at resection by the referring endoscopist had occurred in 167 patients (12.3%). EMR with complete lesion excision

Discussion

Over the last decade, EMR has evolved into a safe, efficacious, predominantly day-stay technique for the management of large LSL. Despite this many and in some countries most patients are still being managed surgically.¹¹ Large LSL are often found in elderly comorbid patients where surgical mortality may be up to 10%.¹² We have previously shown by modelling using well-validated surgical risk algorithms that EMR for large LSL is safer than surgery. The number needed to treat by EMR to prevent 1

Acknowledgments

The authors thank Nimalan Pathmanathan, MBBS, FRACS, Colorectal Surgeon at Westmead Hospital, Sydney, New South Wales, for reviewing the surgical outcome estimates.

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: Conflicts of interest The authors disclose no conflicts.

: Funding Dr Mahesh Jayanna is supported by a grant from the National Health and Medical Research Council of Australia. The Cancer Institute of New South Wales provided funding for a research nurse and data manager to assist with the administration of the study. There was no influence from the National Health and Medical Research Council or the Cancer Institute on study design or conduct, data collection and management, analysis, interpretation, preparation and review, or approval of the manuscript.

^a: Authors share co-first authorship.

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Original articleAlimentary tractCost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions

Background & Aims

Methods

Results

Conclusions

Section snippets

Study Design, Setting, and Patients

Patient and Lesion Characteristics

Discussion

Acknowledgments

Lancet

Gastroenterology

J Gastrointest Surg

Gastroenterology

Lancet

Gastrointest Endosc

Am J Gastroenterol

Clin Gastroenterol Hepatol

Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths

N Engl J Med

Original article
Alimentary tract
Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions