769 Optical Diagnosis of Small Colorectal Polyps With Resect and Discard Strategy Is Cost Saving

Optical Diagnosis of Small Colorectal Polyps With Resect and Discard Strategy Is Cost Saving Sarah K. McGill*, Roy M. Soetikno, Lauren Yokomizo, Jeremy D. Goldhaber-Fiebert, Doug Owens, Tonya Kaltenbach Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA; Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford University School of Medicine, Stanford, CA; Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA Background: Cost savings, reduced polypectomy-related complications, and improved patient communication of surveillance intervals are proposed advantages of a “resect and discard” strategy in which the pathology of small ( 10mm) colorectal polyps is optically diagnosed at colonoscopy in real time. Aims: To evaluate the lifetime clinical and economic consequences of an optical strategy in which small polyps are diagnosed at colonoscopy, adenomas are resected and discarded without formal pathologic evaluation, and small rectosigmoid hyperplastic polyps are left in situ, to a pathology strategy in which there is universal resection and histologic analysis of all polyps, and to that of no screening. Methods: We developed a decision analytic microsimulation model using TreeAge software with a cohort of 100,000 US 50-yr-olds undergoing first screening colonoscopy to compare optical vs. pathology vs. no screening strategies. We derived sensitivity of 91% and specificity of 83% for optical diagnosis with Narrow Band Imaging to predict adenomas against pathology by performing meta-analysis of the literature (28 studies) and fitting a hierarchical summary receiver operating characteristics curve. We based costs on Medicare, CRC incidence on SEER, surveillance intervals on Multi-Society guidelines, and adenoma prevalences and transition probabilities on the literature. We used Markov states: no polyps; hyperplastic polyps; small, medium and large tubular adenomas; undiagnosed and diagnosed local, regional and metastatic colorectal cancer, and death. We calculated lifetime health-related costs, quality-adjusted life year gained (QALYS, both discounted at 3%), complications of colonoscopy (perforations and bleeding) and development of CRC. We estimated annual cost savings projected onto the population as the last U.S. census estimated 4.5 million people with the age of 50, and adherence to colonoscopy screening at around 23%. Results: The optical strategy would result in $30 million yearly in cost savings. The optical strategy saved $28.47 per person per lifetime as compared to the pathology strategy, with no change in quality-adjusted life years. The mean cost (and QALYs gained) per patient was as follows: $199,336 (15.95) for optical strategy, $199,365 (15.95) for pathology, and $195,735 (15.75) for no screening. The incremental cost-effectiveness ratio (ICER) of optical strategy over no screening was $17,162/QALY gained. Lifetime CRC incidence per 1,000 was 15.3 for optical strategy, 15.2 for traditional strategy and 54.9 for no screening. Colonoscopy-related complications per 1000 were 5.3 in the optical strategy and 6.5 in the pathology strategy groups. Conclusion: The practice of optical diagnosis for small colorectal polyps can lead to major cost savings and reduces colonoscopy-related perforation and bleeding without changing the expected QALYs.