Title: Evidence-based diagnosis and management of upper digestive hepato-biliary and pancreatic disorders
Funder: Department of Health (England)

Abstract: Upper digestive system hepato-biliary and pancreatic disorders (which correspond to the chapter GA GB GC and part of FZ of HRG4) account for approximately £1.3 billion annually (4% of the £32.6 billion spent annually by NHS trusts in England for which detailed breakdown is available). In a state-funded healthcare system like NHS the focus is to deliver the best possible care with the resources available. Outcomes such as complications related to the disease or treatment (short-term medium-term and long-term) and quality of life are important for the patient. From a funder perspective the important outcomes include the above along with costs of treatment and complications of the disease and treatment. The clinicians treating these disorders need a quick and authoritative resource on which to base important clinical decisions. Such a database needs to be up-to-date easy to access with information delivered in simple language. The Cochrane Database of Systematic Reviews satisfies most of these criteria. However in many situations the conventional Cochrane reviews only provide partial information since they include only two treatments even when multiple treatments are available for treating the disorder. The patient and clinician have to perform unvalidated and informal indirect comparisons for decision making. Network meta-analysis recently introduced to Cochrane overcomes this problem by using statistically robust and validated methods of analysis to rank multiple treatments and provides the patients and clinicians with quick and comprehensive information. Medicine has undergone a major transformation over the last 15 to 20 years with a rapid increase in the volume and nature of interventions and diagnostic tests for patients with upper digestive disorders. New diagnostic tests have been introduced but are often more expensive than their predecessors and therefore require evidence that they are superior. Imaging has been transformed with new generations of CT scans magnetic resonance imaging endoscopic ultrasound positron emission tomography. The imaging most appropriate under a given clinical situation must be confirmed. Surgery has focused on laparoscopic approaches some of which have transformed healthcare and others which may be premature for the technology available making them dangerous to the patient. New costly drugs have entered into the market. It is necessary to evaluate the incremental improvement in healthcare resulting from using new technology and administering these new drugs using the best methods that are available currently. This programme funded by NIHR will include 30 Cochrane reviews related to upper digestive system. These Cochrane reviews address diagnosis and management of common conditions (eg peptic ulcer) life threatening conditions (acute pancreatitis) chronic conditions (chronic hepatitis B and C infections chronic pancreatitis) or cancer (various gastrointestinal cancers) which affect the survival or quality of life and cause significant expenditure to NHS. We will use standard Cochrane methodology for direct comparisons and NICE DSU (National Institute for Health and Clinical Care Excellence Decision Support Unit) for network meta-analysis. Our reviews focus on the following domains of NHS priority: 1. Preventing people from dying prematurely. 2. Enhancing quality of life for people with long-term conditions. 3. Helping people to recover from episodes of ill-health. The current NHS priority is to deliver patient-centred and customer-focussed healthcare. Of the different aspects of this priority our reviews will address the aspects related to listening to patients and increasing their participation and higher standards and safer care. Many of these reviews are likely to be used in national or international guidelines and will allow patients clinicians and healthcare funders to make informed decisions. We will also undertake six model-based cost-utility analyses estimating mean costs and quality-adjusted life years per patient from the perspective of the NHS using an appropriate time horizon. Topics will be selected from the list of 30 Cochrane reviews in discussion with the steering committee. Appropriate models will be constructed and populated with probabilities outcomes and cost data from published sources including the Cochrane reviews. We will undertake one-way and probabilistic sensitivity analyses budget impact analyses. Where there is uncertainty in cost-effectiveness estimates we will compute the population expected value of perfect information - a measure of the maximum amount that the NHS should be willing to pay for additional research to reduce uncertainty. In addition to the 30 Cochrane reviews and 6 cost-effectiveness analyses we will also compare the results of network analyses results using existing information in systematic reviews versus network analyses with a new search and data extraction. The former will be relatively quick while the latter gives relatively more accurate estimates. Any difference in the results in terms of change of statistical significance and the relative ratios (for binary count time-to-event outcomes) or percentage change in magnitude of effect (for continuous outcomes) will be calculated as appropriate. The steering committee will then decide whether network meta-analysis with new searches and data extraction provides value for money.


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: ORAL AND GASTROINTESTINAL