146 modern medical practices that offer no benefit
Never before in the history of civilization have we witnessed such significant strides in the advancement of medicine like we have in recent decades. Yet, in spite of all this progress, outdated medical treatments continue to be used when newer, more modern treatments are available.
Indeed, a new study published in Mayo Clinic Proceedings documents 146 contemporary medical practices that have subsequently been reversed.
The study involved a team of researchers led by Vinay Prasad, M.D., Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD., who reviewed ten years of original articles published in the New England Journal of Medicine testing standard of care.
"The purpose of our investigation was to outline broad trends in medical practice and identify a large number of practices that don't work," says 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."
Between 2001 and 2010, Dr. Prasad and his research team evaluated 1,344 original articles published in the New England Journal of Medicine that examined a new medical practice or tested an established one, including an assessment of a screening, stratifying, or diagnostic test, a medication, a procedure or surgery, or any change in health care provision systems.
As a result, the team made several interesting discoveries. For example, they found that only a minority of studies over the last 10 years even tested current medical practices, and Prasad found that only 27 percent that tested a practice tested an established one. Rather, 73 percent of such studies tested a new medical practice.
"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," said Prasad, whose major conclusion concerns the 363 articles that test current medical practice, or what things the doctors are doing today.
Prasad and his team determined that 40.2 percent found these practices to be ineffective, or medical reversals. Another 38 percent reaffirmed the value of current practice, and 21.8 percent were inconclusive, or unable to render a firm verdict regarding the practice.
"A large proportion of current medical practice, 40 percent, was found to offer no benefits in our survey of 10 years of the New England Journal of Medicine,” Prasad said.
“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," Prasad explained.
"Health care costs now threaten the entire economy,” added Prasad. “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."
Examples of medical reversal include stenting for stable coronary artery disease, which was a multibillion dollar a year industry even though it was found to be no better than medical management for most patients with stable coronary artery disease.
Another example is hormone therapy for postmenopausal women, which was supposed to improve cardiovascular outcomes even though it was found to be worse than no intervention.
Other examples include the use of the drug aprotinin in cardiac surgery, and the use of a primary rhythm control strategy for patients with atrial fibrillation.
"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," said Prasad.
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, commented on the work of Prasad and his team in an accompanying editorial that provided a broader perspective.
"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," wrote 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."
SOURCE: Mayo Clinic Proceedings, Volume 88, Issue 8 (August 2013), "A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices," by Vinay Prasad, MD; Andrae Vandross, MD; Caitlin Toomey, MD; Michael Cheung, MD; Jason Rho, MD; Steven Quinn, MD: Satish Jacob Chacko, MD; Durga Borkar, MD; Victor Gail, MD; Senthil Selvaraj, MD; Nancy Ho, MD; and Adam Cifu, MD (DOI: http://dx.doi.org/10.1016/j.mayocp.2013.05.012). "Editorial: How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less?" by John P.A. Ioannidis, MD, DSc (DOI: http://dx.doi.org/10.1016/j.mayocp.2013.05.010), published July 22, 2013.