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

ABSTRACT: 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.

SUBMITTER: Eusebi LH

PROVIDER: S-EPMC7190054 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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

Eusebi Leonardo H LH Black Christopher J CJ Howden Colin W CW Ford Alexander C AC

BMJ (Clinical research ed.) 20191211

<h4>Objective</h4>To determine the effectiveness of management strategies for uninvestigated dyspepsia.<h4>Design</h4>Systematic review and network meta-analysis.<h4>Data sources</h4>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.<h4>Eligibility criteria for selecting studies</h4>Randomised controlled trials that assessed the e ...[more]

PMID: 31826881

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Project description:ObjectivesTo compare the clinical effectiveness and cost-effectiveness of labour induction methods.MethodsWe conducted a systematic review of randomised trials comparing interventions for third-trimester labour induction (search date: March 2014). Network meta-analysis was possible for six of nine prespecified key outcomes: vaginal delivery within 24 hours (VD24), caesarean section, uterine hyperstimulation, neonatal intensive care unit (NICU) admissions, instrumental delivery and infant Apgar scores. We developed a decision-tree model from a UK NHS perspective and calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit, and cost-effectiveness acceptability curves.Main resultsIn all, 611 studies comparing 31 active interventions were included. Intravenous oxytocin with amniotomy and vaginal misoprostol (?50 ?g) were most likely to achieve VD24. Titrated low-dose oral misoprostol achieved the lowest odds of caesarean section, but there was considerable uncertainty in ranking estimates. Vaginal (?50 ?g) and buccal/sublingual misoprostol were most likely to increase uterine hyperstimulation with high uncertainty in ranking estimates. Compared with placebo, extra-amniotic prostaglandin E2 reduced NICU admissions. There were insufficient data to conduct analyses for maternal and neonatal mortality and serious morbidity or maternal satisfaction. Conclusions were robust after exclusion of studies at high risk of bias. Due to poor reporting of VD24, the cost-effectiveness analysis compared a subset of 20 interventions. There was considerable uncertainty in estimates, but buccal/sublingual and titrated (low-dose) misoprostol showed the highest probability of being most cost-effective.ConclusionsFuture trials should be designed and powered to detect a method that is more cost-effective than low-dose titrated oral misoprostol.Tweetable abstractNew study ranks methods to induce labour in pregnant women on effectiveness and cost.

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

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

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