Many medical practices worse than doing nothing

24 July 2013

A new analysis published in Mayo Clinic Proceedings has documented 146 medical practices currently in use that have no benefit.

A team of researchers led by Dr Vinay Prasad, of the Medical Oncology Branch, US National Cancer Institute, reviewed ten years of original articles published in the New England Journal of Medicine testing standard of care.

Dr Prasad and his team evaluated 1,344 original articles published between 2001 and 2010 that examined a new medical practice or tested an established one. This included assessment of a screening, stratifying, or diagnostic test, a medication, a procedure or surgery, or any change in health care provision systems.

Only 27% of articles that tested a practice tested an established one. Instead, the vast majority of such studies, 73% (981/1344), tested a new medical practice. Of the current medical practices examined, 40.2% (146) were found to be ineffective, or medical reversals. Another 38% reaffirmed the value of current practice, and 21.8% were inconclusive.

“The purpose of our investigation was to outline broad trends in medical practice and identify a large number of practices that don’t work,” said Dr Prasad. “Identifying medical practices that don’t work is necessary because the continued use of such practices wastes resources, jeopardizes patient health, and undermines trust in medicine.”

“While the next breakthrough is surely worth pursuing, knowing whether what we are currently doing is right or wrong is equally crucial for sound patient care. A large proportion of current medical practice, 40%, was found to offer no benefits in our survey of 10 years of the New England Journal of Medicine. These 146 practices are medical reversals. They weren’t just practices that once worked, and have now been improved upon; rather, they never worked. They were instituted in error, never helped patients, and have eroded trust in medicine.

“Healthcare costs now threaten the entire economy. Our investigation suggests that much of what we are doing today simply doesn’t help patients. Eliminating medical reversal may help address the most pressing problem in health care today.”

Key examples of medical reversal

Stenting for stable coronary artery disease was a multibillion dollar a year industry when it was found to be no better than medical management for most patients with stable coronary artery disease. Hormone therapy for postmenopausal women intended to improve cardiovascular outcomes was found to be worse than no intervention. The routine use of the pulmonary artery catheter in patients in shock was found to be inferior to less invasive management strategies.

Other instances pertain to the use of the drug aprotinin in cardiac surgery, use of a primary rhythm control strategy for patients with atrial fibrillation, use of cyclooxygenase 2 inhibitors, early myringotomy procedures, and application of recommended glycemic targets for patients with diabetes.

Dr Prasad added, “To our knowledge, this is the largest and most comprehensive study of medical reversal. The reversals we have identified by no means represent the final word for any of these practices. But, the reversals we have identified, at the very least, call these practices into question.”

Editorial

In an accompanying editorial, John P. A. Ioannidis, MD, DSc, of the Stanford Prevention Research Center, Department of Medicine and the Department of Health Research and Policy at Stanford University School of Medicine, comments on the work of Prasad and his team and evaluates it within a broader context.

“The 146 medical reversals that they have assembled are, in a sense, examples of success stories that can inspire the astute clinician and clinical investigator to challenge the status quo and realize that doing less is more,” notes Dr Ioannidis. “If we learn from them, these seemingly disappointing results may be extremely helpful in curtailing harms to patients and cost to the health care system.”

According to Dr Ioannidis, it is just as important to promote and disseminate knowledge about ineffective practices that should be reversed and abandoned. Given the widespread attention that practice guidelines typically receive, particularly when published by authoritative individuals or groups, he questions whether a generally higher level of evidence should be required before these guidelines are recommended and can impact clinical practice.

“Finally, are there incentives and anything else we can do to promote testing of seemingly established practices and identification of more practices that need to be abandoned? Obviously, such an undertaking will require commitment to a rigorous clinical research agenda in a time of restricted budgets,” concludes Dr. Ioannidis. “However, it is clear that carefully designed trials on expensive practices may have a very favorable value of information, and they would be excellent investments toward curtailing the irrational cost of ineffective health care.”

References

1. Prasad V, et al. A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices. Mayo Clinic Proceedings, Volume 88, Issue 8 (August 2013). doi: http://dx.doi.org/10.1016/j.mayocp.2013.05.012

2. John PA Ioannidis. Editorial: How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less? Mayo Clinic Proceedings, Volume 88, Issue 8 (August 2013). doi: http://dx.doi.org/10.1016/j.mayocp.2013.05.010