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Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis
- Source :
- The BMJ
- Publication Year :
- 2019
- Publisher :
- BMJ, 2019.
-
Abstract
- ObjectiveTo determine the effectiveness of management strategies for uninvestigated dyspepsia.DesignSystematic review and network meta-analysis.Data sourcesMedline, 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 studiesRandomised 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).ResultsThe 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 registrationPROSPERO registration number CRD42019132528.
- Subjects :
- medicine.medical_specialty
Blinding
Network Meta-Analysis
MEDLINE
Helicobacter Infections
03 medical and health sciences
0302 clinical medicine
Gastrointestinal Agents
Internal medicine
Anti-Bacterial Agent
Gastrointestinal Agent
Gastroscopy
medicine
Humans
030212 general & internal medicine
Dyspepsia
Gastrointestinal agent
Helicobacter pylori
medicine.diagnostic_test
business.industry
Research
General Medicine
Confidence interval
Anti-Bacterial Agents
Endoscopy
Test (assessment)
Relative risk
Meta-analysis
030211 gastroenterology & hepatology
business
Helicobacter Infection
Human
Subjects
Details
- ISSN :
- 17561833
- Database :
- OpenAIRE
- Journal :
- BMJ
- Accession number :
- edsair.doi.dedup.....0ebd13bda21c4948caf7f291ec33ef7f