Publication bias affected the estimate of postoperative nausea in an acupoint stimulation systematic review

Background and ObjectiveTo assess the effect of publication bias and country effect on the results and conclusion of a systematic review of wrist P6 acupoint stimulation for the prevention of postoperative nausea and vomiting.MethodsReanalysis of a systematic review of 26 randomized trials comparing P6 acupoint stimulation with sham published in the Cochrane Database of Systematic Reviews using the Copas' sensitivity approach.ResultsIf it is assumed that all studies that have ever been carried out are included, or that those selected for review are truly representative of all such studies, then the estimated relative risk (RR) for nausea was 0.71 (95% CI: 0.58 to 0.88, P < .01) and for vomiting was 0.70 (95% CI: 0.56 to 0.88, P < .01) after adjusting for country effect. For nausea, adjustment for publication bias suggests that the risk has been overestimated. If around 33% of studies have been unpublished, the RR of nausea (0.92, 95% CI: 0.80 to 1.06, P = .25) is no longer significant. For vomiting, however, there is no strong evidence of publication bias. The number of unpublished studies required to substantially overturn the above significant result is implausibly large.ConclusionPublication bias affects the published estimate of postoperative nausea, not vomiting.