Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Clin Gastroenterol Hepatol. 2013 Oct;11(10):1319-24. doi: 10.1016/j.cgh.2012.12.044. Epub 2013 Jan 30.
BACKGROUND & AIMS: Delayed bleeding after lower endoscopy and polypectomy can cause significant morbidity. One strategy to reduce bleeding is to place an endoscopic clip on the polypectomy site. We used decision analysis to investigate the cost-effectiveness of routine clip placement after colon polypectomy.
Probabilities and plausible ranges were obtained from the literature, and a decision analysis was conducted by using TreeAge Pro 2011 Software. Our cost-effectiveness threshold was an incremental cost-effectiveness ratio of $100,000 per quality-adjusted life year. The reference case was a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy. We estimated postpolypectomy bleeding rates for patients receiving no medications, those with planned resumption of antiplatelet therapy (nonaspirin), or those receiving anticoagulation therapy after polypectomy. We performed several sensitivity analyses, varying the cost of a clip and hospitalization, number of clips placed, clip effectiveness in reducing postpolypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement.
On the basis of the reference case, when patients did not receive anticoagulation therapy, clip placement was not cost-effective. However, for patients who did receive anticoagulation and antiplatelet therapies, prophylactic clip placement was a cost-effective strategy. The cost-effectiveness of a prophylactic clip strategy was sensitive to the costs of clips and hospitalization, number of clips placed, and clip effectiveness.
Placement of a prophylactic endoscopic clip after polypectomy appears to be a cost-effective strategy for patients who receive antiplatelet or anticoagulation therapy. This approach should be studied in a controlled trial.
内镜下结肠息肉切除术（colonoscopy with polypectomy）后延迟性出血可能导致严重的发病率。减少出血的一种策略是在内镜下息肉切除部位放置夹闭装置。我们使用决策分析来研究结直肠息肉切除术后常规夹闭的成本效益。
从文献中获取概率和合理范围，并使用 TreeAge Pro 2011 软件进行决策分析。我们的成本效益阈值为每增加 1 个质量调整生命年（quality-adjusted life year, QALY）的增量成本效益比为 10 万美元。参考病例为一名 50 岁的患者，在结肠镜检查期间切除单个 1.0-1.5cm 的息肉。我们估计接受非药物治疗、计划恢复抗血小板治疗（非阿司匹林）或息肉切除后接受抗凝治疗的患者的息肉切除术后出血率。我们进行了多次敏感性分析，改变夹闭装置和住院费用、放置夹闭装置的数量、夹闭装置减少息肉切除术后出血的效果、与胃肠道出血相关的患者效用天数减少以及夹闭装置放置的危害概率。
根据参考病例，当患者未接受抗凝治疗时，夹闭装置并不具有成本效益。然而，对于接受抗凝和抗血小板治疗的患者，预防性夹闭装置是一种具有成本效益的策略。预防性夹闭装置策略的成本效益对夹闭装置和住院费用、放置夹闭装置的数量以及夹闭装置的效果敏感。
对于接受抗血小板或抗凝治疗的患者，息肉切除术后放置预防性内镜夹闭装置似乎是一种具有成本效益的策略。这种方法应该在对照试验中进行研究。
