Prophylactic Clip Closure After Resection of Right-Sided Colon Polyp Saves Money

By Marilynn Larkin

December 03, 2019

NEW YORK (Reuters Health) - Routine clip closure after endoscopic mucosal resection (EMR) of large colon polyps is cost-saving overall, but the savings are driven mainly by closure of right-sided polyps, a budget-impact analysis reveals.

Dr. Ryan Law of Michigan Medicine in Ann Arbor and colleagues constructed a model to predict healthcare costs based on whether routine prophylactic clip closure was attempted to close a submucosal defect after complete EMR of a large (at least 20 mm in diameter) colon polyp using one of several strategies.

The reference case was a 65-year-old Medicare-eligible individual with at least one medical comorbidity undergoing colonoscopy.

As reported online November 15 in Gastroenterology, the baseline risk of post-procedure bleeding after EMR of a large colon polyp without prophylactic clip closure was 7%, according to pooled randomized clinical trial data from 899 patients.

The risk was higher for right-sided colon polyps proximal to or including the hepatic flexure (9.5%) and lower for left-sided colon polyps (1.4%). The average cost of one bleeding event was $6,458.05 in the constructed scenario.

Translating the risk into a cost burden spread across all patients undergoing large colon polyp resection resulted in a $453.44 excess cost-per-patient. For those with a right-sided large polyp, the excess cost was $614.11. The cost burden increased with greater medical comorbidities, necessitating higher payer reimbursement.

Routine clip closure after EMR of large colon polyps was cost-saving overall; however, the savings were driven mainly by prophylactic clip closure of right-sided polyps.

Specifically, clip closure after EMR of a large right-sided polyp resulted in a 70.7% risk reduction in post-polypectomy bleeding compared to no clip closure, leading to cost savings of $434.09.

By contrast, routine clip closure after EMR of a large left-sided polyp did not decrease the post-procedure bleeding rate and was not cost-saving.

When examining other patient and polyp factors, polyp location was the most important polyp-specific factor driving cost-savings.

Alternative routine clip closure strategies focused on extra-large polyps (at least 40 mm in diameter) regardless of location, or on individuals taking peri-procedural antithrombotic medications, regardless of polyp characteristics. These strategies resulted in 62.9% and 69.2% reductions in post-procedure bleeding, However, the absolute decrease in risk was small, and so the cost savings were lower.

Dr. Law told Reuters Health by email, "There are no times where prophylactic clip closure should not be considered; however, submucosal defects following removal of very large polyps may be difficult to completely close."

"Available data are unable to address whether, and to what degree, partial closure provides protection against delayed bleeding," he noted. "In addition, clip closure is unnecessary following cold snare EMR (i.e., no electrocautery is used for polyp removal). This is due to an exceptionally low (near 0%) risk of adverse events using this technique."

Dr. Anton Bilchik, chief of gastrointestinal research and of medicine at the John Wayne Cancer Institute at Providence Saint John's Health Center in Santa Monica, commented in an email to Reuters Health, "Removal of large colon polyps are increasingly being performed. Bleeding is a known complication and can have dire consequences. Anything to prevent bleeding is essential to improve outcomes and reduce cost."

"I suspect that if these procedures are mainly done in outpatient physician-owned surgery centers, cost is likely to be a major factor," he noted. "This is less likely to be a factor in the hospital setting if the clips are easily available."


Gastroenterol 2019.