Endoscopic full-thickness resection and its treatment alternatives in difficult-to-treat lesions of the lower gastrointestinal tract: a cost-effectiveness analysis

Armin Kuellmer, Juliane Behn, Torsten Beyna, Brigitte Schumacher, Alexander Meining, Helmut Messmann, Horst Neuhaus, David Albers, Michael Birk, Andreas Probst, Martin Faehndrich, Thomas Frieling, Martin Goetz, Robert Thimme, Karel Caca, Arthur Schmidt, Armin Kuellmer, Juliane Behn, Torsten Beyna, Brigitte Schumacher, Alexander Meining, Helmut Messmann, Horst Neuhaus, David Albers, Michael Birk, Andreas Probst, Martin Faehndrich, Thomas Frieling, Martin Goetz, Robert Thimme, Karel Caca, Arthur Schmidt

Abstract

Objective: Endoscopic full-thickness resection (EFTR) has shown efficacy and safety in the colorectum. The aim of this analysis was to investigate whether EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives.

Design: Real data from the study cohort of the prospective, single-arm WALL RESECT study were used. A simulated comparison arm was created based on a survey that included suggested treatment alternatives to EFTR of the respective lesions. Treatment costs and reimbursement were calculated in euro according to the coding rules of 2017 and 2019 (EFTR). R0 resection rate was used as a measure of effectiveness. To assess cost-effectiveness, the average cost-effectiveness ratio (ACER) and the incremental cost-effectiveness ratio (ICER) were determined. Calculations were made both from the perspective of the care provider as well as of the payer.

Results: The cost per case was €2852.20 for the EFTR group, €1712 for the standard endoscopic resection (SER) group, €8895 for the surgical resection group and €5828 for the pooled alternative treatment to EFTR. From the perspective of the care provider, the ACER (mean cost per R0 resection) was €3708.98 for EFTR, €3115.10 for SER, €8924.05 for surgical treatment and €7169.30 for all pooled and weighted alternatives to EFTR. The ICER (additional cost per R0 resection compared with EFTR) was €5196.47 for SER, €26 533.13 for surgical resection and €67 768.62 for the pooled rate of alternatives. Results from the perspective of the payer were similar.

Conclusion: EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives in the colorectum.

Trial registration: ClinicalTrials.gov NCT02362126.

Keywords: colorectal adenomas; colorectal cancer; cost-effectiveness; endoscopic polypectomy.

Conflict of interest statement

Competing interests: AS and KC received lecture fees and study grants from Ovesco Endoscopy, Tübingen, Germany. AK, JB, TB, BS, AM, HM, HN, DA, MB, AP, MF, TF, MG and RT have no conflicts of interest or financial ties to disclose.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Case costs (€) for the different treatment modalities are shown. Costs from the perspective of the third-party payer (reimbursement) are shown in black, while actual case costs from the perspective of the care provider are shown in grey. Surgery: mean costs for TEM and laparoscopic surgical oncological resection. SER: mean costs for ESD and EMR. Casemix: mean costs for ESD, EMR, TEM and laparoscopic surgery. EFTR, endoscopic full-thickness resection; EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; SER, standard endoscopic resection; TEM, transanal endoscopic microsurgery.
Figure 2
Figure 2
Average cost-effectiveness ratio (€) for the different treatment modalities is shown. Costs from the perspective of the third-party payer (reimbursement) are shown in black, while actual case costs from the perspective of the care provider are shown in grey. Surgery: mean costs for TEM and laparoscopic surgical oncological resection. SER: mean costs for ESD and EMR. Casemix: mean costs for ESD, EMR, TEM and laparoscopic surgery. EFTR, endoscopic full-thickness resection; EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; SER, standard endoscopic resection; TEM, transanal endoscopic microsurgery.
Figure 3
Figure 3
Incremental cost-effectiveness ratio for the different treatment modalities compared with EFTR is shown. Costs from the perspective of the third-party payer (reimbursement) are shown in black, while actual case costs from the perspective of the care provider are shown in grey. Surgery: mean costs for TEM and laparoscopic surgical oncological resection. SER: mean costs for ESD and EMR. Casemix: mean costs for ESD, EMR, TEM and laparoscopic surgery. EFTR, endoscopic full-thickness resection; EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; SER, standard endoscopic resection; TEM, transanal endoscopic microsurgery.

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