Value-of-information analysis to guide future research in the management of the colorectal malignant polyp.

PURPOSE

The efficacy of surgery in the postendoscopic management of low-risk malignant polyps is unclear. Although interobserver variability in the histological diagnosis was shown, its importance is unknown. The purpose of this study was to guide future research on the optimal strategy for low-risk polyps with the use of value-of-information analysis.

METHODS

A decision-analysis model was constructed comparing the strategies of referring or not referring (waiting) to surgery patients with low-risk polyps. Probabilistic sensitivity analysis was performed to explore the effect of uncertainty about the input parameters. Value-of-information analysis was used to estimate the expected benefit of future research that would eliminate the decision uncertainty.

RESULTS

The number of postendoscopic surgeries to prevent 1 cancer-related death was 208. The incremental cost-effectiveness ratio of surgery vs waiting strategy was $215,291/life-year gained, surgery being a suboptimal choice in the reference case analysis. Probabilistic sensitivity analysis demonstrated that surgery was the optimal choice in 61% of the simulated scenarios. Most of the decision uncertainty was related with the combination of histological inaccuracy, prevalence of residual disease, and surgical mortality. The expected societal monetary benefit of further research from the perspective of the United States was estimated to be $1 billion.

CONCLUSIONS

The small benefit and the relatively high costs associated with surgery argue against surgical referral for low-risk malignant polyps; however, when a suboptimal histopathological accuracy was simulated, surgery appeared to be the most cost-effective option, prompting the need for further research.