miércoles, 12 de junio de 2019

New study finds almost 400 established medical practices that don’t work

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By Dr. Liji Thomas, MDJun 12 2019

A new study set out to explore what does and does not work in the field of modern medical practice, and came up with 396 reported reversals of previously accepted medical practice over the last few decades.

A medical reversal refers to a low-value medical practice, which is found to either be ineffective or more costly than an earlier or lower standard of care without offering more benefit, following a randomized controlled trial (RCT) which minimizes some types of bias. Auditing medical practice is essential in reducing costs on unnecessary medical interventions, and in protecting human health. Low-value medical practices also eat away at trust in healthcare providers, and may hinder timely access to medical care when required.

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It is difficult to identify such medical reversals. High-quality Cochrane reviews are limited in number. Another initiative is Choosing Wisely, in the US, which invites medical professionals to submit their list of low-value medical practices, but this too is often dependent on professional consensus before it includes a new item in its list.

Study author Herrera-Perez says, “We wanted to build on these and other efforts to provide a larger and more comprehensive list for clinicians and researchers to guide practice as they care for patients more effectively and economically.”

The current study used three medical journals with wide impact, namely, the Journal of the American Medical Association (JAMA), The Lancet, and the New England Journal of Medicine(NEJM), to perform a comprehensive search for RCTs that identified medical reversals. A full 13% all published RCTs were medical reversals. Strikingly, almost two-thirds of these studies were funded by non-industry sources and another 22% from a combination of industry and non-industry sources.

Most of the medical reversals were based on studies done in developed countries, with only 8% having been performed in China, India and other low- or middle-income countries.

The greatest number of reversals (20%) related to cardiovascular disease, followed by 12% in public health and 11% in critical care. In one third, a medication was found ineffective, while 20% dealt with ineffective procedures, and 13% with a vitamin or supplement. Only 1% related to over-the-counter medication use.

Some reversals cited include the immediate delivery of babies following preterm prelabor rupture of the membranes after 34 weeks of pregnancy but before 37 weeks are complete, to reduce newborn sepsis. Others include the universal use of protective gowns and gloves to reduce the spread of methicillin-resistant Staphylococcus aureus (MRSA) in ICUs; mammography every 1-2 years after the age of 40 (not recommended until 50 years); the use of compression stockings to prevent clots in the leg veins after surgery; wearable technology for weight loss; and hormone replacement therapy for menopausal women’s health. None of these are now recommended.

This list is both long and spans all medical disciplines, adding to 146 already reported reversals. Some of these practices are extremely costly though ineffective. For instance, the drug bevacizumab which received US FDA approval for the treatment of metastatic breast cancercost $88,000 per year, but its approval was withdrawn just three years later because of the lack of improvement in overall survival.

Other low-value but costly medical practices adopted by patients themselves include cognitive behavioral therapy, acupuncture, supplementation with omega-3 fatty acids, and wearable technology used by exercisers who want to lose weight.

Once a practice has come into vogue, even for short periods, it is difficult to persuade both patients and medical professionals to abandon it. One way to reduce the number of medical reversals is to insist on having proof of effectiveness in the form of RCTs before the widespread adoption of either novel or older practices. This should be possible for most practices.

Of course, some limitations are present, including the search of only three journals, with the possible impact of editorial choice as to which articles are or are not included; different opinions as to the benefits of various medical interventions, and the fact that in each RCT, the conclusions are based on that of the study authors. The meta-analyses used were not checked for quality, but the most recent research was used to evaluate the reversal.

Nonetheless, study author Vinay Prasad says, “We hope these findings propel medical professionals to critically evaluate their own practices and, going forward, demand high-quality research before adopting a practice, especially for practices that are costlier and/or more aggressive than standard of care.”

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