In the popular press, the oft-cited example in this regard is antibiotics for simple earache.1 Most people assume that antibiotics are effective for the treatment of earache. Anyone with children has brought them to a clinic for an earache and has come out with a prescription for an antibiotic. It’s what we do in our society. However, on average, antibiotics are not very effective for earache. They often seem like it, but it’s only because earaches naturally tend to clear up on the third or fourth day, which is typically just a day or two after starting the medication. The sequence of events makes it seem that there is a cause and effect going on, though in all but a small minority of cases there actually isn’t.
The field of chronic pain management has an abundance of examples of commonly delivered procedures and therapies that are known to be fairly ineffective. The most notable of them are spine surgeries, spinal injections, and long-term narcotic pain medication use. Numerous clinical trials, naturalistic studies, healthcare utilization studies, and epidemiological data all point to the fact that the widespread use of these procedures and therapies are largely ineffective on average for people with back or neck pain.2, 3, 4, 5, 6, 7, 8, 9, 10 Some can even reduce the chances of actually going back to work or can increase utilization of healthcare services.11, 12, 13, 14 Despite this lack of empirical support, spine surgeries, spinal injections and the long-term use of narcotic pain medications are among the most commonly delivered treatments for chronic back or neck pain. Indeed, over the last few decades, their use has grown exponentially.15
The delivery of ineffective care occurs in many areas of healthcare. In fact, the list of common procedures and therapies that are ineffective is rather lengthy. From antibiotics for acute bronchitis to PSA screening for prostrate cancer to the use of vitamin D supplementation to prevent bone fractures, people in our society routinely undergo care that is known to be ineffective.
So, how did it get this way?
Causes of delivering ineffective healthcare
The delivery of ineffective care can occur in many ways. To be clear, though, it’s not because healthcare providers are intentionally swindling unsuspecting, vulnerable patients like the snake oil salesman of yesteryear. By and large, healthcare providers are typically trustworthy. Nonetheless, a lot of care gets delivered that is not, on average, very effective. It can happen in various ways.
Problems with disseminating research findings
The traditional specializations of healthcare disciplines can sometimes interfere with the dissemination of research data that show what’s most effective. Healthcare providers tend to remain within their traditional discipline when interacting with other providers. For instance, within the field of chronic pain management, surgeons tend to go to surgical conferences; interventional pain physicians tend to go to interventional pain conferences; rehabilitation providers, like pain psychologists, tend to go to rehabilitation conferences. In this way, by and large, we don’t tend to cross over to other disciplines. We also don’t tend to read each other’s professional journals. Moreover, all healthcare providers, like any other field, tend to do what we were taught and, of course, we were taught by providers from within our own field. Still further, providers tend to seek out continuing education within their respective disciplines. This state of affairs can remain largely harmless until one field comes to have a procedure or therapy that is shown to be effective for a particular condition or more effective than therapies from the other disciplines. These other disciplines can tend to remain ignorant of the innovation or ignorant of the scientific research that supports it. Their practice patterns, in other words, continue as before, providing procedures and therapies that are less effective relative to those that have been found to be more effective.
Even within a traditional specialization, dissemination of empirically-supported treatments remains agonizingly slow. The Institute of Medicine16 estimated that it takes between fifteen and twenty years before an effective treatment (as demonstrated by research) is in common use. This fact points to an unfortunate gap in our healthcare system between researchers and practitioners. Researchers tend to reside in academic or corporate settings and practitioners tend to reside in clinics and hospitals. There is little opportunity for interaction between the two settings. Moreover, practitioners have numerous competing demands on their time besides the task of keeping up with the latest scientific research findings. Indeed, healthcare providers do not have specific time set aside in their clinic schedules for the purpose of keeping abreast of the latest research. Instead, on their own time, they rely on reading professional journals and attending conferences – the two main traditional vehicles for disseminating scientific research findings to practitioners. Given the Institute of Medicine’s findings, these vehicles are obviously inefficient.
Sometimes, of course, dissemination of research findings occur much faster. It happens when corporations innovate and they subsequently disseminate their findings with well-funded marketing strategies. Such strategies tend to be direct-to-provider marketing, with sales representatives persuading practitioners to recommend or prescribe their product, or direct-to-consumer marketing with television and magazine advertisements, persuading patients to ask for their products.
When, however, innovation occurs outside the corporate world, dissemination of the more effective treatment occurs much more slowly because they have no well-funded marketing strategy. As a result, they must rely on the much more slow and more traditional dissemination vehicles, professional journals and conferences. Take, for example, rehabilitation strategies for chronic disease management. Examples are interdisciplinary cardiac rehabilitation, diabetes education, and chronic pain rehabilitation. Such care focuses on teaching patients to make healthy lifestyle changes, which beneficially affects their disease and their ability to cope with their disease. Research consistently shows that these therapies are some of the most effective treatments available for chronic disease. And yet you might not ever see a television commercial extolling their benefits. You also wouldn’t see sales representatives in, say, your cardiologist’s office talking to the providers about why they should more often recommend interdisciplinary cardiac rehabilitation to patients. As a result, demand for such effective therapies remains low and what tends to get recommended are the less effective single modality treatments – medications alone without the health behavior change coaching – in part because it’s the medications that have the marketing strategies.
No vehicle to educate the public on research findings
Consumer demand is another avenue that leads to the delivery of ineffective care. Just like healthcare providers, society in general takes time to catch up to what research shows is most effective. As we've seen, there are widespread societal beliefs about the effectiveness of various procedures and therapies (such as the use of antibiotics for earache or spine surgery for back pain), even when those procedures and therapies are not effective. It's understandable that these beliefs continue. Who is responsible for correcting them? What would be needed is something on the order of a mass marketing campaign, something akin to what was used to change our previous societal beliefs about tobacco use. The campaign to educate the public that smoking is bad for one's health took time and a significant amount of capital. There is no designated entity that is responsible for securing such capital or carrying out such edu-marketing campaigns.
Even when healthcare providers are knowledgeable about the research, they might not have enough time to explain why societal expectations are wrong. The typical allotted time of about fifteen minutes per patient is simply not enough to explain why antibiotics for an earache or narcotic pain medication for back ache is not in the best interests of a patient. Such discussions run the risk of not going over well and dissatisfied patients can subsequently take even more time. Many in the field quietly acknowledge that sometimes it’s just easier to do what’s expected of them.
This scenario between provider and patient can play itself out not only when research comes to identify a new treatment as effective, but, more importantly, also when research shows that a traditional treatment is in fact ineffective. It may be surprising to learn that many treatments in healthcare enter into the armamentarium of therapies before systematic research determines them to be effective. It happens in many ways, such as when a medication comes to be used on an ‘off label’ basis – for a condition that it was not initially intended to treat. For instance, a provider might find that a medication inadvertently helps a different condition than the one for which the medication was originally prescribed and so the provider begins to use it for this additional condition with other patients. Other providers catch on and also begin using it for the other condition. In this manner, an 'off label' use of a medication can become common. Surgical procedures too are often introduced before there is systematic research showing their effectiveness. Procedures are developed because conceptually it makes sense that they should work. In any of these cases, some patients of course benefit. Most any treatment will yield benefit to some people. In actual clinical practice, these successes can influence the decision-making of providers and reinforce the continued 'off label' use of the medication or procedure. At some point, researchers take up the treatment, garner funding, and perform a large scale, difficult to undertake, clinical trial of the medication or procedure and come to find that it’s no better than placebo – that, yes indeed, some people benefit, but the treatment provides no additional benefit over and above the placebo benefit. This process of research can take many years. By this time, the treatment or procedure may have become a traditional treatment that both providers and patients expect should work. As such, the medication or procedure may continue to be used despite its proven lack of effectiveness.
Once demonstrated, the research findings face the further hurdle of getting disseminated on a widespread basis. Since negative findings (i.e., the demonstration that a treatment is ineffective) never have a marketing team behind them, their dissemination must rely on the slower, traditional vehicles of professional journal publications and conference lectures. As we’ve seen, the time it takes to disseminate such findings is lengthy, more than a decade. Meanwhile, ineffective treatments continue in common practice until the findings are disseminated and accepted on a wide-scale basis.
Perhaps, it is in these ways that we currently continue to provide antibiotics for simple earache and spinal surgeries for back and neck pain. If so, we might consider their use as occurring within this in-between period: the studies have been published but widespread practice has not yet assimilated them and consequently practice patterns have not yet changed.
The profit-motive may also play a role in the persistent delivery of healthcare that is ineffective. We have a capitalistic system that incentivizes the delivery of procedures and therapies. The more care a provider or provider organization delivers, the more money they make. There is very little incentive to not treat someone or send them to another provider who might deliver a more effective therapy. Rather then sending a sick or hurting patient away empty handed, healthcare providers tend to provide something along with the referral to the more effective care. However, the treatment that patients leave with is often not very effective.
Incentivizing the delivery of care also tends to lower the bar for when care should be delivered. In a capitalistic system, it is easy to justify a treatment recommendation on the basis that the treatment might work. That is to say, any procedure or therapy might help someone, even if, on average, the therapy does not help most people. So, it is not untrue or misleading to think that any given treatment might work for a particular patient. Now, if providers are at the same time incentivized to provide care, then the justification that ‘it might work’ can become good enough to give the procedure or therapy a try. That is to say, in our current capitalistic system, there’s no incentive to only provide care that has a higher level of justification, such as only providing treatment that is likely to work. As such, healthcare providers can maintain a good conscience when providing care that, on average, is not very effective. The justification is that it might help and it’s not untrue or misleading. The rub is that many procedures and therapies, as we have seen, are just not likely to help.
While we have already discussed its role in the dissemination of research, marketing can also influence the delivery of care towards providing ineffective therapies in yet another way. For example, new FDA-approved medications often come with great fanfare – television commercials, glossy magazine ads, witty internet videos, and sales representatives who sell healthcare providers on the idea of prescribing the medication. Sometimes, these medications are not as effective as older medications. It’s important to know, in this regard, that FDA approval for widespread use of a medication only means that the medication is better than a placebo and that it has passed tests of safety. FDA approval does not mean that the medication is better than medications that are already on the market for the same condition.17 As such, when a new medication has a lot of marketing behind it, it tends to get prescribed more than older medications for the same condition, even if the older medications are more effective. As a result, less effective care gets delivered.
Society's tendency to externalize responsibility for health
Lastly, society overall tends to view healthcare as something we rely on to make us better. In doing so, we subtly externalize responsibility for our own health. This shift in responsibility is all well and good if the healthcare system actually has a cure for what ails us. It seems, for instance, eminently advisable to give up responsibility for my well-being to an acute care surgeon when I have appendicitis. By doing so, I get better by relying on the surgical procedure and the surgeon who provides it. This shift in responsibility is more problematic though in cases of chronic disease – chronic pain, heart disease, diabetes, obesity and the like. The acute medical model of care has no cure for these conditions. Nevertheless, having externalized responsibility, we tend as a society to continue to rely on procedures, therapies and medications, as if such acute care is the most effective. The rub is that they aren’t the most effective.
As indicated above, what is most effective for chronic health conditions are rehabilitation therapies. Such care focuses on teaching and motivating patients to take back responsibility for their health and engage in lifestyle changes that make them healthier. However, health behavior change – the most effective therapy for chronic health conditions – is notoriously difficult to engage patients in doing and is often the last thing that healthcare providers recommend or the last thing that patients are willing to do – after they have trialed and failed the less effective acute care procedures and therapies.
No doubt there are many reasons why we continue to deliver ineffective healthcare. The list above is not exhaustive. Nonetheless, it can serve as a starting point for a discussion. To be sure, it is an uncomfortable discussion. No one, whether provider or patient, likes to acknowledge when the things we do aren’t working. It’s like airing our dirty laundry.
Despite our discomfort, it’s an important discussion to have. It’s important morally and pragmatically. As healthcare professionals, we should not remain complacent with the status quo. We have an obligation to help people and that obligation requires providing the most effective care on a more routine basis. We should not remain in ignorance of the effectiveness of our care. We need to develop better and more efficient ways to know what is effective. Would any other industry take fifteen to twenty years between the time of innovation and its widespread implementation? While reducing the delivery of ineffective care is the right thing to do, it is also something that will reduce costs for all of us. Whether we get ineffective care or not, we all collectively pay for it through our annual health insurance premiums. It’s time for developing a means to educate, not only providers, but also the public as to what care is effective and what is not. At this time, we have no such vehicle for disseminating this information.
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Date of publication: September 20, 2015
Date of last modification: September 20, 2015