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Reversal of Medical Practices

      To the Editor:
      We recently read with great interest “A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices” by Prasad et al,
      • Prasad V.
      • Vandross A.
      • Toomey C.
      • et al.
      A decade of reversal: an analysis of 146 contradicted medical practices.
      along with the accompanying editorial by Ioannidis.
      • Ioannidis J.P.A.
      How many contemporary medical practices are worse than doing nothing or doing less [editorial]?.
      The authors have done an admirable job of quantitatively analyzing the number of reversals published over a decade in one high-impact journal, of course begging the question of how many reversals might be found across the medical literature. We would like to raise 2 important points. The first is about dissemination of the finding of reversal. It is well known that a new practice or device takes years to promulgate from published evidence of effectiveness to actual routine clinical use; how long does it take for a replaced practice to disappear from clinical use? One can imagine Rogers’ technology adoption lifecycle working in reverse, in which a core of “early abandoners” are followed by the early and late majorities and finally by the laggards.
      • Beal G.M.
      • Rogers E.M.
      • Bohlen J.M.
      Validity of the concept of stages in the adoption process.
      As with the adoption of new interventions, there is also likely to be a substantial minority who persist with the use of a reversed idea, either through ignorance or conviction (or both).
      The second point relates to treatments that were standard of care before the now reversed treatment came along. Do such historical treatments regain prominence when an intermediary is replaced? In order to attempt to answer such a question, we recently published a network meta-analysis of all randomized controlled trials in the first-line treatment of chronic myelogenous leukemia published between 1968 and 2012.
      • Warner J.
      • Yang P.
      • Alterovitz G.
      Automated synthesis and visualization of a chemotherapy treatment regimen network.
      We found 5 distinct epochs, each of which represents a replacement of the preceding epoch, for the treatment of this disease: (1) the busulfan era (1968-1992), (2) the hydroxyurea era (1993-1994), (3) the interferon era (1994-2002), (4) the imatinib era (2003-2009), and (5) the second-generation tyrosine kinase inhibitor (TKI) era (2010 to the present). What we found notable is that even though imatinib was “replaced” in 2010 (in terms of efficacy; toxicities and cost of the second-generation TKIs are considerable, and thus imatinib is still routinely used and recommended), the historical standard (interferon) has never been compared directly to the newest standard (second-generation TKIs). In fact, one might conclude that the “third-generation” drug (interferon) should be carefully reconsidered as a viable option for the treatment of this disease. This and many other examples illustrate the need for systematic and quantitative “medical archeology”—a need that should be prompted by the publication of high-impact reversals such as those found by Prasad et al.
      • Prasad V.
      • Vandross A.
      • Toomey C.
      • et al.
      A decade of reversal: an analysis of 146 contradicted medical practices.
      It is our hope that such analysis of the medical literature will become routine and that a centralized knowledge base will be established to quickly disseminate important findings of reversal.

      References

        • Prasad V.
        • Vandross A.
        • Toomey C.
        • et al.
        A decade of reversal: an analysis of 146 contradicted medical practices.
        Mayo Clin Proc. 2013; 88: 790-798
        • Ioannidis J.P.A.
        How many contemporary medical practices are worse than doing nothing or doing less [editorial]?.
        Mayo Clin Proc. 2013; 88: 779-781
        • Beal G.M.
        • Rogers E.M.
        • Bohlen J.M.
        Validity of the concept of stages in the adoption process.
        Rural Sociology. 1957; 22: 166-168
        • Warner J.
        • Yang P.
        • Alterovitz G.
        Automated synthesis and visualization of a chemotherapy treatment regimen network.
        Stud Health Technol Inform. 2013; 192: 62-66

      Linked Article

      • How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less?
        Mayo Clinic ProceedingsVol. 88Issue 8
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          How many contemporary medical practices are not any better than or are worse than doing nothing or doing something else that is simpler or less expensive? This is an important question, given the negative repercussions for patients and the health care system of continuing to endorse futile, inefficient, expensive, or harmful interventions, tests, or management strategies. In this issue of Mayo Clinic Proceedings, Prasad et al1 describe the frequency and spectrum of medical reversals determined from a review of all the articles published over a decade (2001-2010) in New England Journal of Medicine (NEJM).
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      • A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices
        Mayo Clinic ProceedingsVol. 88Issue 8
      • In reply II—Reversal of Medical Practices
        Mayo Clinic ProceedingsVol. 88Issue 10
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          The implementation time frame of reversals, ie, how long does it take for a replaced practice to disappear from clinical use, is a question that is worthwhile answering with collation of data from multiple reversals. Scattered evidence suggests that the process can be slow and accompanied by resistance from adherents of the refuted practice. Resistance to change may be fueled by financial or professional conflicts of interest. Examples include hormone treatment in postmenopausal women,1-3 vitamins for preventive use,3 and use of percutaneous interventions for stable coronary artery disease that can be well managed with drugs.
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      • In reply I—Reversal of Medical Practices
        Mayo Clinic ProceedingsVol. 88Issue 10
        • Preview
          Warner et al raise 2 important issues regarding our investigation of 146 medical reversals.1 First, how long do contradicted practices persist in clinical practice? One of the reversals we noted informs this point. The use of percutaneous coronary intervention for patients with stable angina was a widespread practice that was largely contracted in 2007 with the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial.2 Although initial evidence suggested decreased use of stenting in the wake of the COURAGE study, more recent data suggest a resurgence of this practice to pre-COURAGE levels.
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