Experts say a lack of research and communication allows some outdated common procedures to continue in practice.
If a doctor or a specialist recommends a treatment, we’re putting our trust in their expert hands.
You expect they’re recommending the tried-and-true, best-tested standard of care — why wouldn’t they?
But a new comprehensive review of more than 3,000 randomized clinical trials has concluded that hundreds of current medical recommendations across various disciplines may not be all that necessary.
Researchers analyzing trials published in three medical journals — the Journal of the American Medical Association, The Lancet, and the New England Journal of Medicine — found 396 “medical reversals” in research from 2003 and 2017.
These add to another 146 recommended reversals from previous research encompassing the years 2001 to 2010, say researchers from Oregon Health & Science University, the University of Maryland School of Medicine, and United University of Chicago.
“The de-adoption of these and other low-value medical practices will lead to cost savings and improvements in medical care,” the study authors write.
In some senses, this isn’t a surprise.
The nature of medical progress — and science itself — is to test new standards and promising results against the older versions and re-evaluate them.
“Sometimes there hasn’t been enough research to date to tell us one way or another whether something is definitely useful or not,” Dr. Christine Chang, associate director for the Evidence-Based Practice Center Program at the Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ), told Healthline. “When the information is lacking, we start practices using the best evidence we have.”
The problem, the researchers say, is that once a practice becomes standard or recommended, it can be hard to even identify if newer clinical trials suggest a different path, let alone get organizations accustomed to certain practice to alter their care.
In terms of finding studies where a medical reversal is recommended, the work currently being done is piecemeal.
For instance, the international nonprofit Cochrane conducts regular systematic reviews of research in order to help determine and set the best medical practice and policy.
But Cochrane’s reviews only focus on one practice at a time and are therefore not comprehensive to the vast array of practices out there.
Similarly, the Choosing Wisely campaign in the United States is a directed effort “to advance a national dialogue on avoiding unnecessary medical tests, treatments, and procedures.”
But that campaign is limited by relying on self-reporting by medical organizations and “often includes only those practices where there is a high degree of consensus,” the study authors write.
When it came to which areas of medicine were subject to the highest number of medical reversals, a few stood out.
Cardiovascular disease represented 20 percent of the medical reversals, followed by preventive medicine and public health (12 percent), and critical care (11 percent).
Medication was the most common intervention, representing 1 in 3 of the reversals the research team found.
Procedural intervention represented 1 in 5 of reversals while vitamins and supplements represented a little more than 1 in 10.
One such medical procedure the researchers found was in the area of mammogram screenings for women under 50.
The American Cancer Society supports mammograms for women ages 40 to 49, but the randomized clinical studies the team reviewed concluded that “no significant difference in breast cancer mortality” for women this age, suggesting this practice should no longer be supported.
While all medical reversals can have serious consequences, the researchers also singled out drug spending as particularly wasteful and inefficient.
“In countries like the U.S., where there was a 20 percent increase in spending between 2013 and 2015, and drug prices alone surpassed the increase in aggregate health care spending, the identification and disuse of costly and ineffective (or possibly harmful) medications and practices are especially important,” the study authors write. “For example, bevacizumab (Avastin) was approved in 2008 by the Food and Drug Administration (FDA) in the U.S. for metastatic breast cancer under the accelerated approval program, but was later shown to not improve overall survival, even though the cost to each patient was $88,000 per year.”
But even situations like this one aren’t as simple as they seem on their face, Chang said.
“With any intervention or practice, when any group recommends it, they look not only the benefits but also the benefits versus harms,” she said. “There are certainly times where there’s uncertainty but there are few choices, so in any of those situations people have to weigh the benefits versus harms and the comfort with those harms.”
In other words, if the choice is to fast-track a drug that might not have the strongest clinical trials behind it but might cure a life-threatening condition, it might be worth trying something and then course correcting later.
This research represents a step toward putting better information in the hands of professionals to make these corrections, but doing so will likely require “a multi-pronged approach,” Chang said.
“In many cases, communication itself — giving an educational pamphlet — may not be enough,” she told Healthline. “You might need a champion in an organization or a group to champion it and let other people know what should be done. There can also be things that help direct people away from an intervention that shouldn’t be done, like through electronic health records, for example.
“So there are different ways of tackling it depending on what the issues are,” she said.