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Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis

OBJECTIVE: To determine the effectiveness of management strategies for uninvestigated dyspepsia. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Medline, Embase, Embase Classic, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov from inception to September...

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Autores principales: Eusebi, Leonardo H, Black, Christopher J, Howden, Colin W, Ford, Alexander C
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group Ltd. 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190054/
https://www.ncbi.nlm.nih.gov/pubmed/31826881
http://dx.doi.org/10.1136/bmj.l6483
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author Eusebi, Leonardo H
Black, Christopher J
Howden, Colin W
Ford, Alexander C
author_facet Eusebi, Leonardo H
Black, Christopher J
Howden, Colin W
Ford, Alexander C
author_sort Eusebi, Leonardo H
collection PubMed
description OBJECTIVE: To determine the effectiveness of management strategies for uninvestigated dyspepsia. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Medline, Embase, Embase Classic, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov from inception to September 2019, with no language restrictions. Conference proceedings between 2001 and 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials that assessed the effectiveness of management strategies for uninvestigated dyspepsia in adult participants (age ≥18 years). Strategies of interest were prompt endoscopy; test for Helicobacter pylori and perform endoscopy in participants who test positive; test for H pylori and eradication treatment in those who test positive (“test and treat”); empirical acid suppression; or symptom based management. Trials reported dichotomous assessment of symptom status at final follow-up (≥12 months). RESULTS: The review identified 15 eligible randomised controlled trials that comprised 6162 adult participants. Data were pooled using a random effects model. Strategies were ranked according to P score, which is the mean extent of certainty that one management strategy is better than another, averaged over all competing strategies. “Test and treat” ranked first (relative risk of remaining symptomatic 0.89, 95% confidence interval 0.78 to 1.02, P score 0.79) and prompt endoscopy ranked second, but performed similarly (0.90, 0.80 to 1.02, P score 0.71). However, no strategy was significantly less effective than “test and treat.” Participants assigned to “test and treat” were significantly less likely to receive endoscopy (relative risk v prompt endoscopy 0.23, 95% confidence interval 0.17 to 0.31, P score 0.98) than all other strategies, except symptom based management (relative risk v symptom based management 0.60, 0.30 to 1.18). Dissatisfaction with management was significantly lower with prompt endoscopy (P score 0.95) than with “test and treat” (relative risk v “test and treat” 0.67, 0.46 to 0.98), and empirical acid suppression (relative risk v empirical acid suppression 0.58, 0.37 to 0.91). Upper gastrointestinal cancer rates were low in all trials. Results remained stable in sensitivity analyses, with minimal inconsistencies between direct and indirect results. Risk of bias of individual trials was high; blinding was not possible because of the pragmatic trial design. CONCLUSIONS: “Test and treat” was ranked first, although it performed similarly to prompt endoscopy and was not superior to any of the other strategies. “Test and treat” led to fewer endoscopies than all other approaches, except symptom based management. However, participants showed a preference for prompt endoscopy as a management strategy for their symptoms. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42019132528.
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spelling pubmed-71900542020-05-01 Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis Eusebi, Leonardo H Black, Christopher J Howden, Colin W Ford, Alexander C BMJ Research OBJECTIVE: To determine the effectiveness of management strategies for uninvestigated dyspepsia. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Medline, Embase, Embase Classic, the Cochrane Central Register of Controlled Trials, and clinicaltrials.gov from inception to September 2019, with no language restrictions. Conference proceedings between 2001 and 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials that assessed the effectiveness of management strategies for uninvestigated dyspepsia in adult participants (age ≥18 years). Strategies of interest were prompt endoscopy; test for Helicobacter pylori and perform endoscopy in participants who test positive; test for H pylori and eradication treatment in those who test positive (“test and treat”); empirical acid suppression; or symptom based management. Trials reported dichotomous assessment of symptom status at final follow-up (≥12 months). RESULTS: The review identified 15 eligible randomised controlled trials that comprised 6162 adult participants. Data were pooled using a random effects model. Strategies were ranked according to P score, which is the mean extent of certainty that one management strategy is better than another, averaged over all competing strategies. “Test and treat” ranked first (relative risk of remaining symptomatic 0.89, 95% confidence interval 0.78 to 1.02, P score 0.79) and prompt endoscopy ranked second, but performed similarly (0.90, 0.80 to 1.02, P score 0.71). However, no strategy was significantly less effective than “test and treat.” Participants assigned to “test and treat” were significantly less likely to receive endoscopy (relative risk v prompt endoscopy 0.23, 95% confidence interval 0.17 to 0.31, P score 0.98) than all other strategies, except symptom based management (relative risk v symptom based management 0.60, 0.30 to 1.18). Dissatisfaction with management was significantly lower with prompt endoscopy (P score 0.95) than with “test and treat” (relative risk v “test and treat” 0.67, 0.46 to 0.98), and empirical acid suppression (relative risk v empirical acid suppression 0.58, 0.37 to 0.91). Upper gastrointestinal cancer rates were low in all trials. Results remained stable in sensitivity analyses, with minimal inconsistencies between direct and indirect results. Risk of bias of individual trials was high; blinding was not possible because of the pragmatic trial design. CONCLUSIONS: “Test and treat” was ranked first, although it performed similarly to prompt endoscopy and was not superior to any of the other strategies. “Test and treat” led to fewer endoscopies than all other approaches, except symptom based management. However, participants showed a preference for prompt endoscopy as a management strategy for their symptoms. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42019132528. BMJ Publishing Group Ltd. 2019-12-11 /pmc/articles/PMC7190054/ /pubmed/31826881 http://dx.doi.org/10.1136/bmj.l6483 Text en © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
spellingShingle Research
Eusebi, Leonardo H
Black, Christopher J
Howden, Colin W
Ford, Alexander C
Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
title Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
title_full Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
title_fullStr Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
title_full_unstemmed Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
title_short Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
title_sort effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7190054/
https://www.ncbi.nlm.nih.gov/pubmed/31826881
http://dx.doi.org/10.1136/bmj.l6483
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