A, Responses that support, are neutral toward, or challenge the reversal of practice (P=.003). B, Responses that recommend, are neutral toward, or do not recommend that all or some patients should use the reversed intervention (P=.01). The numbers above each bar are the number of responses in each category.
Wang MTM, Gamble G, Grey A. Responses of Specialist Societies to Evidence for Reversal of Practice. JAMA Intern Med. 2015;175(5):845-848. doi:10.1001/jamainternmed.2015.0153
Medical reversal—when a current practice is found to be no better than, or inferior to, a prior standard—is common1 and inconsistently translated into practice.2 Continuing use of ineffective treatments wastes resources and harms patients.3 There may be multiple reasons for persistence of reversed practices. Commercial entities may resist evidence of reversal that threatens profitability.4 Academic and/or specialist biases might also contribute to persistence of reversed practices. Specialist societies strongly influence clinical practice in their specific disciplines.5 We analyzed the responses of specialist societies to publication of evidence for medical reversal.
We identified 20 examples of medical reversal (12 medical, 5 procedural, and 3 screening) reported by 24 publications in major internal medicine journals (Table). We searched EurekAlert!, Web of Science, and Google for responses (press releases, position statements, and clinical guidelines) of specialist societies to the publication of evidence for reversal of practice, restricting the analysis to the first response from a society on a topic. For comparison, we analyzed journal responses (editorials and clinical practice articles) published in the same issue as the source publication. Two of us (M.T.M.W. and A.G.) independently rated each response as supportive of, neutral toward, or challenging the reversed practice and recommending, neutral toward, or not recommending use of the intervention in some or all patients. Consensus to resolve differences was required for 10% of the assessments. We rated the reversed practice as being of high (n = 100), moderate (n = 44), or low (n = 12) importance to members of the responding society. Each ordinal dependent variable was modeled using Proc Genmod in SAS, version 9.4 (SAS Institute Inc) to explore differences between the sources of the responses, controlling for collinearity between responses made to the same study. Interaction terms were included in the fully saturated model to assess potential determinants of resistance.
We analyzed 156 specialist society responses, with a median time since publication of the evidence for reversal of practice of 591 days (range, 2-4115 days), and 21 journal responses. Specialist society responses were more supportive of, and less likely to challenge, the reversed practice than were journal responses (supportive, 49% vs 24%; challenge, 31% vs 62%; P = .003) and were more likely to recommend the reversed practice for all or some patients (recommend, 54% vs 29%; not recommend, 31% vs 57%; P = .01) (Figure). Resistance to reversal of practice by specialist societies was greater when the reversed practice was assessed to be very important to its members (P < .001). No interaction was found between resistance to reversal, source of response, and either level of prior supporting evidence or type of intervention.
Specialist societies are moderately resistant to medical reversal. The notion that “specialist bias” favors continuation of reversed practices is supported by our findings because journal responses were less resistant to changing practice and specialist societies’ resistance to reversal was related to the importance of the reversed practice to members of the responding society. Publications favorably disposed toward reversed practices are predominantly found in specialty journals.2 Journal responses may also be susceptible to bias: selection of editorial authors might favor endorsement of the reversing publication, thus reducing resistance, or editorial authors might have academic investment in the reversed practice, thus favoring resistance.
Our findings might reflect inherent conservatism among physicians, but physicians were not conservative in adopting most of the reversed practices without rigorous supporting evidence (Table). Interpretive biases favoring greater stringency in evaluating evidence that challenges established ideas, discounting of data by selective criticism of methods, and adherence to arguments of plausibility6 may be enhanced among specialists. Academic and commercial conflicts within specialist societies5 may also contribute to resistance to reversal. Within specialist societies, greater involvement of methods experts and nonspecialists in evaluating new evidence and minimization of commercial conflicts might improve the translation of reversing evidence into clinical practice.
Corresponding Author: Andrew Grey, MD, Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand (firstname.lastname@example.org).
Published Online: March 16, 2015. doi:10.1001/jamainternmed.2015.0153.
Author Contributions: Dr Grey had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Wang, Grey.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Grey.
Critical revision of the manuscript for important intellectual content: Wang. Gamble.
Statistical analysis: Wang, Gamble.
Conflict of Interest Disclosures: None reported.
Funding/Support: Funding for this study was provided by the Health Research Council of New Zealand and the University of Auckland.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.