The Answer to "When to Clip" After Colorectal Endoscopic Mucosal Resection Based on a Cost-Effectiveness Analysis

Area of Science:

• Gastroenterology
• Endoscopic Surgery
• Health Economics

Background:

• Delayed bleeding (DB) is a significant complication following endoscopic mucosal resection (EMR).
• Clip closure after EMR of large nonpedunculated colorectal polyps (LNPCPs) has shown promise in reducing DB.
• The cost-effectiveness of this prophylactic measure requires careful evaluation.

Purpose of the Study:

• To analyze the cost-effectiveness of prophylactic clip closure after EMR for LNPCPs.
• To determine if selective or universal clip closure strategies are economically viable.
• To assess the utility of the GSEED-RE2 DB risk score in identifying high-risk patients.

Main Methods:

• A prospective multicenter database of 2,263 EMRs from 2,130 patients was analyzed.
• Patients were stratified using the GSEED-RE2 DB risk score.
• Cost-effectiveness analysis was conducted in Spanish and US economic contexts, using established ICER thresholds.

Main Results:

• Universal clip closure was not cost-effective in either economic context (ICERs: 469,706 € in Spain, $1,258,641 in the US).
• Selective clip closure in the high-risk GSEED-RE2 subgroup was cost-saving in Spain (-2,194 €) and cost-effective in the US ($87,796).
• DB rates decreased significantly with clip closure, particularly in high-risk groups.

Conclusions:

• Prophylactic clip closure is cost-effective for patients undergoing EMR of large colorectal lesions who are at high risk of delayed bleeding.
• The GSEED-RE2 DB risk score is a valuable tool for identifying this high-risk population, enabling targeted interventions.
• Selective application of clip closure based on risk stratification optimizes resource allocation and improves patient outcomes.