Cold Versus Hot Endoscopic Mucosal Resection for ≥15 mm Large Nonpedunculated Colorectal Polyps

Introduction: Endoscopic mucosal resection (EMR) is the standard approach for managing large nonpedunculated colorectal polyps (LNPCPs ≥15 mm). Hot EMR (H-EMR) offers low recurrence rates but carries a higher risk of delayed postpolypectomy bleeding (DPPB), while cold EMR (C-EMR) has a more favorable safety profile, but its higher recurrence rates remain a concern. Given these trade-offs, we conducted a cost-effectiveness analysis comparing C-EMR and H-EMR for LNPCPs. Methods: We conducted an incremental cost-effectiveness analysis over a 6-month time horizon using a decision tree model informed by the pooled data of randomized studies evaluating C-EMR versus H-EMR. Costs—including for EMR, delayed bleeding, and hospitalization—were derived from CMS reimbursement data and published sources. The Incremental Cost-Effectiveness Ratio (ICER) was determined for the base patient undergoing H-EMR versus C-EMR for LNPCPs. Analysis was performed using TreeAge Pro Health care 2024. Results: Pooled data from RCTs comprising 1516 LNPCPs (766 in C-EMR and 750 in H-EMR group) in 1442 patients were utilized. In the base case of a 66.8-year-old patient undergoing endoscopic resection for LNPCPs, C-EMR was associated with an incremental cost of −$286.67, incremental effectiveness of 0.0004282, resulting in an incremental cost-effectiveness ratio (ICER) of −$669,448 per QALY. This indicates that C-EMR is cost-effective compared with H-EMR at a WTP threshold of $100,000 per QALY. Conclusion: Our analysis shows that C-EMR is a cost-effective strategy compared with H-EMR for LNPCPs ≥15 mm. While H-EMR offers lower recurrence rates, its higher rates of adverse events—such as DPPB and perforation—contribute to increased costs and reduced overall effectiveness.