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Researchers Identify Contemporary Medical Practices That Offer No Benefits

Journal review finds 146 clinical failures (July 22)

While there is an expectation that newer medical practices improve the standard of care, the history of medicine reveals many instances in which this has not been the case. Reversal of established medical practice occurs when new studies contradict current practice. A new analysis published in the Mayo Clinic Proceedings documents 146 contemporary medical practices that have subsequently been reversed.

Researchers evaluated 1,344 original articles published in the New England Journal of Medicine 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.

A total of 363 articles tested current medical practice. The investigators determined that 146 (40.2%) found these practices to be ineffective, or medical reversals. Another 138 (38%) reaffirmed the value of current practice, and 79 (21.8%) were inconclusive.

Lead author Vinay Prasad, MD, commented: “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.”

Key examples of medical reversals include the following:

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; the use of cyclooxygenase 2 (COX-2) inhibitors; early myringotomy procedures; and the application of recommended glycemic targets for patients with diabetes.

In an accompanying editorial, John P. A. Ioannidis, MD, DSc, of the Stanford University School of Medicine, said: “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. 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; August 2013.

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