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手术干预与药物干预的证据可及性及比较效果:系统评价概述

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews.

作者信息

Zavalis Emmanuel A, Rameau Anaïs, Saraswathula Anirudh, Vist Joachim, Schuit Ewoud, Ioannidis John P A

机构信息

Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden.

Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA.

出版信息

medRxiv. 2023 Feb 1:2023.01.30.23285207. doi: 10.1101/2023.01.30.23285207.

Abstract

OBJECTIVES

To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored.

DESIGN

Systematic review of systematic reviews (umbrella review).

DATA SOURCES

Cochrane Database of Systematic Reviews (CDSR).

ELIGIBILITY CRITERIA AND SYNTHESIS OF RESULTS

Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses.

RESULTS

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs.

CONCLUSIONS

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed.

PROTOCOL REGISTRATION

https://osf.io/p9x3j.

摘要

目的

研究手术与药物治疗方案比较的普遍性、此类比较的证据强度,以及手术或药物干预是否更受青睐。

设计

对系统评价进行系统综述(伞状综述)。

数据来源

Cochrane系统评价数据库(CDSR)。

入选标准及结果综合

在CDSR中使用检索词“surg*”,我们检索了手术干预的系统评价。随后筛选摘要以找到旨在比较手术与药物干预的系统评价;然后,在这些评价中,找到那些包含此类比较的任何随机对照试验(RCT)的评价。试验结果数据手动提取并综合成随机效应荟萃分析。

结果

总体而言,188项系统评价旨在比较手术与药物。只有41项纳入了至少一项RCT的数据(总计165项有数据的RCT),涵盖了手术与药物各种比较的总共103种不同结局。Cochrane综述作者对这些评价中的87项(83%)结局进行了GRADE评估,表明证据强度在4项结局中为高(4%),22项(21%)为中,27项(26%)为低,33项(32%)为极低。基于95%置信区间,手术干预在38/103(37%)的结局中更受青睐,药物在13/103(13%)的结局中更受青睐。在GRADE评级为高的结局中,只有一项显示出决定性的优越性(肛裂的括约肌切开术优于药物治疗)。在GRADE评级为中等的22项结局中,6项(27%)无定论,14项(64%)支持手术,2项(9%)支持药物。

结论

尽管了解手术与药物干预的相对优缺点对许多疾病很重要,但高强度的随机证据很少。需要更多比较手术与药物干预的随机试验。

方案注册

https://osf.io/p9x3j。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ff04/9915830/3c24ae7b6c4e/nihpp-2023.01.30.23285207v1-f0001.jpg

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