Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysisBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6483 (Published 11 December 2019) Cite this as: BMJ 2019;367:l6483
- Leonardo H Eusebi, senior assistant professor1,
- Christopher J Black, clinical research fellow2 3,
- Colin W Howden, professor of medicine4,
- Alexander C Ford, professor and honorary consultant gastroenterologist2 3
- 1Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- 2Leeds Gastroenterology Institute, St James’s University Hospital, Leeds, UK
- 3Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
- 4Division of Gastroenterology and Hepatology, Department of Medicine, University of Tennessee College of Medicine, Memphis, TN, USA
- Correspondence to: A C Ford Leeds Gastroenterology Institute, St James’s University Hospital, Leeds LS9 7TF, UK @alex_ford12399 on Twitter) (or
- Accepted 7 November 2019
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.
Contributors: LHE, CJB, CWH, and ACF conceived and drafted the study. LHE, CJB, CWH, and ACF analysed and interpreted the data. ACF drafted the manuscript. LHE and CJB contributed equally to the manuscript and are joint first authors. All authors have approved the final draft of the manuscript. ACF is guarantor. ACF accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding: No funding given.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Ethical approval for this evidence synthesis was not required.
Data sharing: No additional data available.
The lead author (ACF) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.
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/.