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20130228 edit, ¿cuánta evid necesitamos para cambiar creencias¿ scott
20130228 edit, ¿cuánta evid necesitamos para cambiar creencias¿ scott
20130228 edit, ¿cuánta evid necesitamos para cambiar creencias¿ scott
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20130228 edit, ¿cuánta evid necesitamos para cambiar creencias¿ scott


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  • 1. EDITORIALForegoing low-value care: how much evidence is needed tochange beliefs?It’s not always easy to let go of time-honoured practiceswhich are shown to be ineffective or even harmful. Aconsiderable literature has grown up around how toencourage clinicians to align their routine practice withrobust scientific evidence.1Much of this ‘implementa-tion’ or ‘translation’ research has focused on explainingand overcoming underuse of effective interventions.2Thelandmark CareTrack study of the quality of healthcarein Australia3estimated that just over 40% of eligiblepatients do not receive evidence-based care. On the flipside, widespread use of ineffective interventions, whichmay consume up to 30% of healthcare budgets,4hasreceived much less attention at a time when healthcaresystems are required, by fiscal constraints, to maximisehealth benefit for every dollar spent.5Clinicians are often reluctant to relinquish establishedclinical practices despite seemingly compelling evidenceto do so. For example, US studies showed no decreasein the use of percutaneous coronary intervention (PCI)to reopen totally occluded infarct-related arteriesbeyond 24 h after acute myocardial infarction despitepublication of a large trial showing no benefit andrelease of revised guidelines.6Similar experience hasbeen noted in regards to PCI use in patients with stable,non-critical coronary artery disease.7In many hospitals,protocols decree that batteries of preoperative tests,routine replacement of intravenous cannulae every fewdays and daily chest X-rays on all intensive carepatients be performed, irrespective of clinical need –despite considerable evidence that more selective, lesscostly manoeuvres are equally safe and effective.8Futile, aggressive care delivered to patients withadvanced end-stage disease or terminal illness dimin-ishes dignity and quality of life while consumingresources. Potential waste and possible harm also occurwhen an intervention proven to be effective within avery specific population is inappropriately applied to awider spectrum of patients for whom benefit has neverbeen demonstrated (indication creep). More than onein five implantable cardioverter-defibrillators in the USare inserted for off-label indications for which benefithas not been evaluated.9To healthcare funders and policymakers, clinicianresistance to foregoing interventions that robust evidencereveals are of no benefit, or even harmful, is perplexing,to say the least. The question they may well ask is: howmuch evidence do you need to change your mind?Determinants of decision-makingClinicians will rightly argue that evidence has to be com-pelling before they disown practices that have stood thetest of time and, in their personal experience at least,appear safe and to have done some good. However, whatconstitutes ‘compelling’ evidence is very much in the eyeof the beholder, although two themes predominate: epis-temic factors around the trustworthiness of the research(objectivity, consistency, clinical plausibility and non-selective reporting of outcomes) and the likely benefit forindividual patients (effect size, applicability of ‘averagestudy patient’ treatment effects to specific subgroups orunselected real-world populations, time to effect, andvalue to patients of the outcomes measured).10Still, thethreshold of ‘compellingness’ that may serve as a ‘tippingpoint’ for a collective change in beliefs remains uncertain,at least in the medical world, and will likely differ fromone clinical scenario to the next.Moreover, research evidence is not the only determi-nant of clinical decision-making. Various cognitive andnon-cognitive factors may explain the tendency towardsunnecessary care,7,11–15with many reflecting cliniciandesire to avoid potential injustice to individuals fromwithholding interventions that may possibly bestowsome benefit (Table 1). However, while these factors areno doubt important, there are two more fundamentalfactors that may underpin resistance to change.Cognitive dissonanceCognitive dissonance is the inability to reconcile newevidence with highly ingrained prior beliefs that bothdetermine and are reinforced by routinised practice16–one believes so one does, and as one does, so one believes.Such beliefs are highly personal and internalised based onindividual experience, interpretation of past research,exposure to the views of respected peers, and socialisationinto the norms and traditions (or culture) of one’s chosenspecialty. What we believe (and want to believe) is tightlybound to the central human need to belong to and seekcomfort within, a group that shares similar values andbs_bs_bannerInternal Medicine Journal 43 (2013)© 2013 The AuthorsInternal Medicine Journal © 2013 Royal Australasian College of Physicians 107
  • 2. outlook. Challenging current professional paradigms runsthe risk of being cast out and ostracised from the group.Pioneering medical thinkers from Ignaz Semmelweis(septic technique to prevent puerperal sepsis) to BarryMarshall (eradication of Helicobacter pylori to preventrecurrent peptic ulcer) have had to confront and over-come collective cognitive dissonance.When research supports strongly held beliefs, clini-cians more readily accept the conclusions – despitemajor methodological flaws – and use them to reinforcecurrent practice17or in some cases add to current prac-tice, even if the evidence is far from definitive.18Incontrast, when research runs counter to strongly heldbeliefs, even multiple studies involving patients repre-sentative of everyday practice may not prove persuasive.All sorts of reasons, including flaws in study designs(both real and imagined) and limited applicability ‘to mypatients’ may be cited to discredit the results.19There arenotable exceptions, chiefly reports that unequivocallyshow serious harm from commonly performed interven-tions, more so if patients get to know about it, raising therisk of medicolegal liability. There was an immediatereduction in the use of hormone replacement therapy inpost-menopausal women20and of prophylactic anti-arrhythmic agents following acute myocardial infarc-tion,21following trials showing increased risk of seriousadverse events, information that was quickly dissemi-nated in the lay press.Professional autonomy and reactanceClinicians value their autonomy and being perceived assound arbiters of medical knowledge. Having to acceptevidence that runs contrary to one’s beliefs and refuteswhat had been regarded as effective interventions canthreaten one’s sense of competence, professionalism andfreedom to choose. This may incite a state of psychologi-cal reactance, a tendency to resist perceived attempts byothers – especially those outside one’s professionalnetwork – to control behaviour.22Individuals can react ina way that affirms their ability to choose and oftenbecome more entrenched in their original beliefs. Oncearoused, reactance may heighten sensitisation to addi-tional threats to freedom of choice that further constrainsthe capacity for dispassionate debate. To date, psychologi-cal reactance of clinicians has been little studied in themedical literature with most reports pertaining to patientnon-adherence with medical advice.23Implications for physician practicePutting these cognitive biases to one side, there is no placefor continued support of ineffective or harmful practicesamong clinical professions that base their practice andauthority on good science. Recent investigations havedisclosed more than 150 high-volume clinical services onthe Medicare Benefits Schedule that are potentially oflow-value, with almost half being ineffective or harmfulon the basis of multiple trials and systematic reviews.8Pastexperience in encouraging clinicians to align practice withbest evidence suggest educational or awareness-raisingstrategies, clinical audits and feedback, academic detailing,and other professionally mediated interventions havelimited impact in curtailing inappropriate care.1Funders and policymakers increasingly view suchactivities as too slow and incremental. Consequently,they place greater faith in ‘forced function’ manoeuvresof which the first and foremost are financial incentives(or increasingly disincentives) in the belief that clini-cians will no longer do things if they are not being paid,or paid as much, to do them. Value-based funding pro-grammes and pay for performance schemes in the USand UK are seeking, rightly or wrongly, to reducefunding for publicly subsidised services deemed to be ofno value and reallocate saved resources to higher valuehealthcare that confers greater benefit. So-called‘bundled payment’ models, for example, provide cleardisincentives for including low-value services in thebundle that attracts a set price for an entire carepackage. Other strategies include public reporting ofquality standards for hospitals (and in the future possi-bly individual units and consultants) that includeTable 1 Biases towards unnecessary care• Clinician regret at not administering a treatment when it may leadto benefit (regret of omission) overpowering regret for theconsequences of an unnecessary treatment (regret of commission)• Pro-intervention bias, especially among younger clinicians, towardschoosing action over inaction even if marginal benefits of action arevery small• Pro-technology and ‘innovation’ bias towards too readily believingthat newer treatments and technologies are superior to theirpredecessors• Desire to please referring clinicians• Fear of patient approbation or litigation for not doing things(defensive medicine);• Supply-driven demand (desire of industry and providers to generateincome in presence of excess capacity)• Overestimation by both clinicians and patients of treatment benefitsand safety• Overreliance on pathophysiological or anatomical reasoning, orsurrogate outcomes that do not necessarily translate intopatient-important benefits• Clinical practice guidelines lacking a sound evidence base or writtenby conflicted panellists• Fee-for-service funding (which rewards quantity not quality ofservices)Editorial© 2013 The AuthorsInternal Medicine Journal © 2013 Royal Australasian College of Physicians108
  • 3. overuse as well as underuse of care, restricting use ofcertain interventions to narrowly defined populations ofeligible patients and highly competent providers inorder to maximise benefit, and increased use of block-ing systems that disallow the ordering or prescribing ofselected tests or treatments. As stewards of tax-payerfunds, Australian authorities will likely consider theseapproaches in the near future.While interventions that are clearly of low valuerepresent low-hanging fruit in any programme aimed atreducing waste, more challenging are interventions ‘atthe margin’ where genuine uncertainty exists as to whowill and will not benefit from them. It is in no one’sinterest to reduce indiscriminately utilisation such thatpatients who clearly need specific interventions aredenied them. If as clinicians, we wish to avoid beingmarginalised in debates around minimising use of inef-fective or harmful interventions and reduce the risk ofbeing governed by policy decree with its inherent clum-siness and potential for unintended consequences, wewill have no choice but to define low-value care andanswer the question ‘how much evidence is enough tochange beliefs?’Received 18 December 2012; accepted 18 December 2012.doi:10.1111/imj.12065I. A. Scott1,2and A. G. Elshaug3,41Internal Medicine and Clinical Epidemiology, Princess AlexandraHospital, 2University of Queensland, Brisbane, Queensland, 3Schoolof Population Health, University of Adelaide, Adelaide, SouthAustralia, Australia and 4Department of Health Care Policy,Harvard Medical School, Boston, Massachusetts, USAReferences1 Scott IA, Glasziou PP. Improvinghealthcare productivity: the need forbetter translation of science intopractice. Med J Aust 2012; 197:374–8.2 Cabana MD, Rand CS, Powe NR, WuAW, Wilson MH, Abboud PA et al. Whydon’t physicians follow clinical practiceguidelines? A framework forimprovement. JAMA 1999; 282:1458–65.3 Runciman WB, Hunt TD, HannafordNA, Hibbert PD, Westbrook JI, CoieraEW et al. CareTrack: assessing theappropriateness of health care deliveryin Australia. Med J Aust 2012; 197:100–5.4 Institute of Medicine. Learning whatworks best: the nation’s need forevidence on comparative effectivenessin health care. National Academies,September 2007. [cited 2012 Dec 12].Available from URL: Katz MH, Grady D, Redberg RF.Undertreatment improves, butovertreatment does not. Arch InternMed 2012. doi: 10.1001/jamainternmed.2013.23616 Deyell MW, Buller CE, Miller LH, WangTY, Dai D, Lamas GA et al. Impact ofNational Clinical Guidelinerecommendations for revascularizationof persistently occluded infarct-relatedarteries on clinical practice in the UnitedStates. Arch Intern Med 2011; 171:1636–43.7 Moscucci M. Behavioral factors, bias,and practice guidelines in the decision touse percutaneous coronary interventionsfor stable coronary artery disease. ArchIntern Med 2007; 167: 1573–5.8 Elshaug AG, Watt AM, Mundy L, WillisCD. Over 150 potentially low-valuehealth care practices: an Australianstudy. Med J Aust 2012; 197: 556–60.9 Al-Khatib SM, Hellkamp A, Curtis J,Mark D, Peterson E, Sanders G et al.Non-evidence-based ICD implantationsin the United States. JAMA 2011; 305:43–9.10 Tonelli MR. Compellingness: assessingthe practical relevance of clinicalresearch results. J Eval Clin Pract 2012;18: 962–7.11 Lenzer J. Unnecessary care: are doctorsin denial and is profit driven healthcareto blame? BMJ 2012; 345: e6230.12 Hajjaj FM, Salek MS, Basra MKA, FinlayAY. Non-clinical influences on clinicaldecision-making: a major challenge toevidence-based practice. J R Soc Med2010; 103: 178–87.13 Doust J, Del Mar C. Why do doctors usetreatments that do not work? BMJ 2002;328: 474–5.14 Emanuel EJ. What cannot be said ontelevision about health care. JAMA2007; 297: 2131–3.15 Djulbegovic B, Paul A. Fromefficacy to effectiveness in the face ofuncertainty: indication creep andprevention creep. JAMA 2011; 305:2005–6.16 Festinger L. A Theory of CognitiveDissonance. Stanford, CA: StanfordUniversity Press; 1957.17 Kaptchuk TJ. Effect of interpretive biason research evidence. BMJ 2003; 326:1453–5.18 Guyatt GH, Briel M, Glasziou P, BasslerD, Montori VM. Problems of stoppingtrials early. BMJ 2012; 344: e3863.19 Rubenfeld GD. Understanding why weagree on the evidence but disagree onthe medicine. Respir Care 2001; 46:1442–9.20 Hersh AL, Stefanick ML, Stafford RS.National use of postmenopausalhormone therapy: annual trends andresponse to recent evidence. JAMA2004; 291: 47–53.21 Preliminary report: effect of encainideand flecainide on mortality in arandomized trial of arrhythmiasuppression after myocardial infarction.The Cardiac Arrhythmia SuppressionTrial (CAST) Investigators. N Engl J Med1989; 321: 406–12.22 Brehm SS, Brehm JW. PsychologicalReactance: A Theory of Freedom andControl. New York, NY: Academic Press;1981.23 Fogarty J. Reactance theory and patientnoncompliance. Soc Sci Med 1997; 45:1277–88.Editorial© 2013 The AuthorsInternal Medicine Journal © 2013 Royal Australasian College of Physicians 109