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The effectiveness of endoscopy in the management of dyspepsia: a qualitative systematic review

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Abstract

PURPOSE: Dyspepsia is a common primary care condition, yet its optimal management is poorly defined. We reviewed the literature to answer the following questions about patients with dyspepsia: 1) Does endoscopy result in improved patient outcomes? 2) Does endoscopy result in a reduction in the use of subsequent medical resources? 3) Does endoscopy result in improved medical decision making? 4) Is endoscopy cost effective?

METHODS: We performed a systematic review of English-language articles in the MEDLINE, HEALTHSTAR, and EMBASE computerized bibliographic databases from January 1985 to July 1998. We included all studies, including decision analyses, with information about the effectiveness of endoscopy, as measured by its impact on patient outcomes, resource utilization, clinical decision making, or cost effectiveness. Two independent reviewers abstracted data from each study, and assessed its methodologic quality.

RESULTS: Twenty-one studies met the inclusion criteria. For 3 of the 4 clinical questions, the weight of evidence does not support the effectiveness of endoscopy. The largest randomized clinical trial comparing endoscopy with empiric therapy demonstrates equivalent symptoms and quality of life at 1 year, with increased patient satisfaction and lower costs for initial endoscopy. Suboptimal study design, including lack of appropriate comparison groups, limit studies measuring the impact of endoscopy on resource utilization and decision-making. Decision analyses indicate that noninvasive H pylori testing followed by anti-H pylori therapy or empiric antisecretory therapy is more cost effective than initial endoscopy.

CONCLUSIONS: With the exception of one randomized clinical trial, the preponderance of available data does not support the effectiveness of endoscopy in the management of dyspepsia. Prospective clinical trials that evaluate patient outcomes and resource utilization, and take H pylori status into account, are needed to determine the effectiveness of endoscopy in the management of dyspepsia.

Section snippets

Literature review

A structured search of three computerized bibliographic databases (MEDLINE, HEALTHSTAR, and EMBASE) was performed to identify English-language articles from January, 1985 to July, 1998. We targeted information on the effectiveness of endoscopy as a diagnostic or therapeutic procedure in the management of dyspepsia. Subject headings, key words, and search strategies were selected in cooperation with an expert librarian experienced in searching health-related computerized databases. Titles were

Results

The search strategy identified 855 citations. One hundred and twelve titles met our initial explicit relevancy criteria, and the abstracts were reviewed independently by both authors. Seven additional titles were identified from hand searching or content experts, and the abstracts were reviewed. Thirty-four abstracts met our explicit inclusion criteria. The kappa value for agreement at the abstract review stage was .70. Disagreement was resolved by consensus. Twenty-one articles met our

Discussion

The rationale for initial endoscopy in the management of dyspepsia is to identify patients with organic disease, particularly ulcers and cancer. The perceived benefits include establishing a firm diagnosis so that specific management may be given, making an early diagnosis of gastric cancer and thus improving survival, and providing reassurance to the patient and physician 12, 22, 23, 66. Although there is a perception that empiric therapy in dyspepsia delays the endoscopic diagnosis of gastric

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    1

    Dr. Rabeneck was supported by the Department of Veterans Affairs Health Services Research and Development (HSR&D) Houston Field Program and is the recipient of a VA HSR&D Career Development Award.

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