Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices

Abstract

Abandoning ineffective medical practices and mitigating the risks of untested practices are important for improving patient health and containing healthcare costs. Historically, this process has relied on the evidence base, societal values, cultural tensions, and political sway, but not necessarily in that order. We propose a conceptual framework to guide and prioritize this process, shifting emphasis toward the principles of evidence-based medicine, acknowledging that evidence may still be misinterpreted or distorted by recalcitrant proponents of entrenched practices and other biases.

Medical Debates and Medical Reversal

“…Deimplementation does not happen rapidly, 3 and recent work suggests that the forces against abandonment are predictable. 2 Commercial entities and specialty societies seem particularly unlikely to embrace data that casts doubt on accepted therapies.…”

Should We Continue to Use Stress Ulcer Prophylaxis for Critically Ill Patients?

“…With the subsequent introduction of proton pump inhibitors (PPIs) came small trials comparing the efficacy of these newer and more potent agents with that of the H2RAs. Several meta-analyses have suggested increased efficacy with PPIs relative to H2RAs for stress ulcer prophylaxis, [5][6][7] but these analyses comprised poor-quality trials that included patients with variable risk of stress ulcers and assessed different outcomes (overt versus clinically important bleeding). The trials varied in sample size from 28 to 359 patients, and were underpowered relative to the landmark Cook trial (n = 1200 patients).…”

“…Individually, neither the larger trials (with sample sizes ranging from 189 to 359 patients) nor the trials with less bias were able to demonstrate a difference in clinically important bleeding between PPIs and H2RAs. 6,7 Furthermore, in one of the few positive, yet frequently referenced trials, 8 the incidence of clinically important bleeding (with endoscopic confirmation of stress ulcers in most patients) was 31% (11/35) in the H2RA arm, compared with 6% (2/32) in the PPI arm. This bleeding rate appears unbelievably high relative to the lower rates in all of the other studies, as well as the contemporary estimates of stress ulcers of less than 5%.…”

“…In contrast, data comparing PPIs with H2RAs in terms of their association with nosocomial pneumonia are conflicting. Although several metaanalyses comparing PPIs and H2RAs showed no difference in the rate of nosocomial pneumonia, [5][6][7] several large observational studies have suggested an increased risk of pneumonia with PPIs relative to H2RAs. 15,16 Similarly, although observational studies have suggested an association between the use of PPIs and C. difficile-associated diarrhea, 14,17 the risk of this problem with use of H2RA appears to be lower.…”

Untitled

“…As good as it sounds, it seems to be just hypothetical. Up to date half of the treatments available in the regular practice do not have enough scientific evidence to support them, furthermore around 1/3rd of them are proved to be ineffective or unsafe however all of them are approved by the regulatory agencies and used by medical doctors everyday [2]. That means half of our medical practice is based on expert opinions, in other words empirical knowledge.…”