The Frequency of Medical Reversal

Prasad, Vinay; Gall, Victor; Cifu, Adam S.

doi:10.1001/archinternmed.2011.295

Cited by 118 publications

(100 citation statements)

References 5 publications

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“…Between 30% and 50% of contemporary trials that test established practices show that the practices confer little or no benefit, in contradiction to prevailing assumptions. 22 Examples include percutaneous coronary artery intervention in stable, non-critical coronary artery disease, 23 facility-based cardiac rehabilitation programs following myocardial infarction, 24 vertebroplasty for acute osteoporotic fracture 25 and blood glucose self-monitoring in stable type 2 diabetes. 26 Such discredited practices tend to persist, often for years, 27 sustained sometimes by vested commercial interests, but more often by strongly held professional beliefs.…”

Section: Minimise Errors In Diagnosismentioning

confidence: 99%

Ten clinician-driven strategies for maximising value of Australian health care

Scott¹

2014

Aust. Health Review

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Objective. To articulate the concept of high-value care (i.e. clinically relevant, patient-important benefit at lowest possible cost) and suggest strategies by which clinicians can promote such care in rendering the Australian healthcare system more affordable and sustainable.Methods. Strategies were developed by the author based on personal experience in clinical practice, evidence-based medicine and quality improvement. Relevant literature was reviewed in retrieving studies supporting each strategy.Results. Ten strategies were developed: (1) minimise errors in diagnosis; (2) discontinue low-or no-value practices that provide little benefit or cause harm; (3) defer the use of unproven interventions; (4) select care options according to comparative cost-effectiveness; (5) target clinical interventions to those who derive greatest benefit; (6) adopt a more conservative approach nearing the end of life; (7) actively involve patients in shared decision making and self-management; (8) minimise day-to-day operational waste; (9) convert healthcare institutions into rapidly learning organisations; and (10) advocate for integrated patient care across all clinical settings.Conclusions. Clinicians and their professional organisations, in partnership with managers, can implement strategies capable of maximising value and sustainability of health care in Australia.What is known about this topic? Value-based care has emerged as a unitary concept that integrates quality and cost, and is being increasingly used to inform healthcare policy making and reform. What does this paper add? There is scant literature that translates the concept of high value care into actionable enhancement strategies for clinicians in everyday practice settings. This article provides 10 strategies with supporting studies in an attempt to fill this gap. What are the implications for practitioners? If all practitioners, in partnership with healthcare managers, attempted to enact all 10 strategies in their workplaces, a significant quantum of healthcare resources could be redirected from low-to highvalue care, culminating in much greater health benefit from the healthcare dollars currently being spent. However, such reforms will require a shift in clinician thinking and practice away from volume-based care to value-based care.

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Section: Minimise Errors In Diagnosismentioning

confidence: 99%

Ten clinician-driven strategies for maximising value of Australian health care

Scott¹

2014

Aust. Health Review

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“…The facility of adequate disposable sets for drainage is the counterpart of the easy-to-get US machines, equipped with reliable and suitable convex and linear probes, and set appropriately for superficial and lung imaging. The traps, in these conditions, are not many and the only risky trap is, as above addressed, over-trusting in US criteria not evidencebased and, more important, which are demonstrated to be unreliable when critically re-appraised; reversal of such scarcely validated but recommended practices, which could be harmful for patients, is actively in progress (32,33) also in this field of medicine.…”

Section: Final Recommendationmentioning

confidence: 99%

Transthoracic ultrasound for pleural effusion: traps and tricks

Sperandeo¹

2014

sob

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SummaryPleural effusion is excess fluid that accumulates between the two pleural layers. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation. Pleural effusion is still usually diagnosed on the basis of medical history and physical examination, and confirmed by chest x-ray. It is observed in many pulmonary and extra-pulmonary disease; its cause can be relatively benign or definitely malign (cancer), and may require drainage for treatment or for achieving a diagnosis which is available at the bedside by physical examination and Thoracic Ultrasound (TUS). Pleural effusion is detected by TUS even when its volume is very little: it is possible to perform and repeat at bedside, by sufficiently trained physicians. Diagnostic intervention procedures are safer if performed using US probes specifically designed for this use, i.e. with a central hole which allows the co-axial passage of the disposable tools for drainage or Fine Needle Aspiration Biopsy (FNAB). Over-trusting in US criteria not evidence-based and, more important, which are demonstrated to be unreliable when critically re-appraised must be discouraged; reversal of such scarcely validated but recommended practices, which could be harmful for patients, is actively in progress also in this field of medicine. No special trick is needed and no actual trap is present when the assessment of pleural effusion is performed by a sufficiently skilled MD and with a reliable and well set echo machine. Echo-assisted thoracentesis is an excellent procedure when appropriately performed in all its phases, which are: choice of the site of insertion, visualization in real-time during the drainage and serial control during lung re-expansion (so as to avoid pneumothorax). KEY WORDS: ultrasound, pleural effusion. Transthoracic ultrasound: overviewThe ultrasound examination in the study of pleuro-pulmonary disease, i.e. Thoracic Ultra-Sound (TUS), is limited by the presence of air in the lungs and by the rib cage (1). As a consequence TUS is not an all purpose tool, drawbacks and appropriate indications must be the cynosure of the pneumologist which relies on TUS for diagnosis and management of patients (2). The presence of the bony structures of the rib cage restricts the success of ultrasound imaging of the pleural surface to about 70% of the total (3). These issues, relating to limitations on the use of ultrasound in the thoracic area, have been known since the ʼ60s, a time when pioneering works were published using A-mode for exploring pleuro-pulmonary structures and, namely, pleural effusion (4), even in comparison with radiological imaging and with a greater sensitivity and specificity (5). Thereafter these advantages were established in the few subsequent years, with minimal further refinements despite the technology of ultrasound equipment has evolved considerably (6, 7): the value of ultrasound examination of the pleura and lungs remains highly underestimated to this day, and overstatements (8) and over- Mini-review...

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“…Prasad reviewed all articles in the 2009 New England Journal of Medicine that made a claim about a medical practice. 18 The articles were divided equally between those that constituted a reversal, those that upheld an existing practice as beneficial, and those that were inconclusive regarding a current practice. Once incorrect findings from earlier studies are refuted by better quality data, it is not a given that they fade into oblivion accompanied by the practices that they supported.…”

Section: Principal Findings -Literature Searchmentioning

confidence: 99%

Review article: The role of practice guidelines and evidence-based medicine in perioperative patient safety

Crosby

2012

Can J Anesth/J Can Anesth

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Purpose The purpose of this narrative review is to discuss the impact of clinical practice guidelines on the outcomes of care and patient safety. Principal findings The care provided to patients has a high degree of variability, including some care that is discordant with available evidence. This inconsistency has implications for patient safety as some patients receive care that is unlikely beneficial yet may be harmful, while others are denied care that would clearly be helpful. The medical literature is expanding at an alarming rate; its quality and reliability is often poor; study methodology is frequently suboptimal, and reversal is common, even among frequently cited articles. For decades, specialty societies and other agencies have been providing clinical practice guidelines to assist physicians with the integration of evidence into clinical decision-making. Implementation of guidelines has been variable, and their goals are often not achieved due to failed uptake and application. The reasons for this shortcoming are complex and some explanations are valid. Many guidelines have not been evidence-based and many have been methodologically unsound. Physician autonomy likely also plays an important role in guideline uptake; an updated concept of autonomy that embraces appropriate guidelines is long overdue. Conclusions Under certain conditions, guidelines can add value to care and improve outcomes; they need to be evidence-based, methodologically sound, and appropriately applied to patients and clinical scenarios. Simply summarizing evidence in a guideline is an inadequate process. To achieve the benefit of guidelines, implementation strategies need to be robust. RésuméObjectif L'objectif de cette analyse est de discuter de l'impact des directives de pratique clinique sur les re´sultats des soins et sur la se´curite´des patients. Constatations principales Le niveau des soins fournis aux patients peut varier dans de grandes proportions, et cela concerne e´galement certains soins qui ne concordent pas avec les donne´es probantes disponibles. Ce manque d'homoge´ne´ite´a des implications sur la se´curite´des patients, car certains d'entre eux reçoivent des soins qui ont peu de chances de leur eˆtre be´ne´fiques ou qui leur sont plutôt ne´fastes, tandis que d'autres se voient refuser des soins qui pourraient manifestement leur eˆtre utiles. Les publications me´dicales se multiplient a`un rythme inquie´tant; leur qualite´et leur fiabilite´sont souvent faibles; la me´thodologie des e´tudes est souvent sous-optimale et leurs conclusions sont souvent contredites, meˆme dans le cas d'articles fre´quemment re´fe´rence´s. Pendant des de´cennies, les socie´te´s savantes de spe´cialistes et les agences gouvernementales ont fourni des directives de pratique clinique pour aider les me´decins a`inte´grer les donne´es probantes dans les processus de prise de de´cision clinique. La mise en oeuvre des directives a e´te´variable et, souvent, leurs objectifs ne sont pas atteints en raison de leur non-adoption par les profe...

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The Frequency of Medical Reversal

Cited by 118 publications

References 5 publications

Ten clinician-driven strategies for maximising value of Australian health care

Ten clinician-driven strategies for maximising value of Australian health care

Transthoracic ultrasound for pleural effusion: traps and tricks

Review article: The role of practice guidelines and evidence-based medicine in perioperative patient safety

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