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

PURPOSE: Dyspepsia is a common primary care condition, yet its optimal mana gement is poorly defined. We reviewed the literature to answer the followin g questions about patients with dyspepsia: 1) Does endoscopy result in impr oved patient outcomes? 2) Does endoscopy result in a reduction in the use o f subsequent medical resources! 3) Does endoscopy result in im proved medic al decision making! 4) Is endoscopy cost effective? METHODS: We performed a systematic review of English-language articles in t he MEDLINE, HEALTHSTAR, and EMBASE computerized bibliographic databases fro m January 1985 to July 1998. We included all studies, including decision an alyses, 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 fr om each study, and assessed its methodologic quality. RESULTS: Twenty-one studies met the inclusion criteria. For 3 of the 4 clin ical questions, the weight of evidence does not support the effectiveness o f 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 endos copy. Suboptimal study design, including lack of appropriate comparison gro ups, limit studies measuring the impact of endoscopy on resource utilizatio n 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 prepo nderance of available data does not support the effectiveness of endoscopy in the management of dyspepsia. Prospective clinical trials that evaluate p atient outcomes and resource utilization, and rake H pylori status into acc ount, are needed to determine the effectiveness of endoscopy in the managem ent of dyspepsia. (C) 1999 by Excerpta Medica, Inc.