Low Value Medical Practices
Marc Hochberg, MD, MPH, MACP, Immediate Past President, USBJI
I have come to the conclusion of my two-year term as President and wish to thank not only my colleagues and friends on the Executive Committee and Board of Directors of the U.S. Bone and Joint Initiative (USBJI) but also the staff of USBJI who work tirelessly in the home office in Rosemont, IL, especially Mr. Toby King and Ms. Shari Maier. I would like to use my last “President’s Message” to comment on a recent article by Herrera-Perez and colleagues in the journal “eLife” that was mentioned in an article in The New York Times on Tuesday, July 2, 2019 by Ms. Gina Kolata. I will mention here that one of my colleagues at the University of Maryland School of Medicine, Dr. Daniel Morgan, was a coauthor of the article in “eLife”.
Low value medical practices are those that either have been found to be ineffective by clinical studies, including randomized controlled trials, or for which there are similarly or more effective treatments that are less expensive or safer. “Choosing Wisely”, an initiative of the American Board of Internal Medicine, was begun in 2012 to have national professional organizations provide a list of five tests or procedures commonly used in their field that were considered to be either unnecessary or of low value. The complete list of recommendations can be found at “https://www.choosingwisely.org/clinician-lists//” and includes, for example, the recommendation not to prescribe opioid analgesics for acute or chronic low back pain before consideration of a trial of alternative medications and treatments (American Academy of Physical Medicine and Rehabilitation and North American Spine Society), not to use lateral wedge insoles, glucosamine and chondroitin and needle lavage to treatment patients with symptomatic osteoarthritis of the knee (American Academy of Orthopedic Surgeons) and not to perform magnetic resonance imaging of peripheral joints to routinely monitor patients with inflammatory arthritis (American College of Rheumatology).
Herrera-Perez and her colleagues added to the concept of low value medical practice and the Choosing Wisely initiative by describing “medical reversals”, a subset of low value medical practices that have been found through randomized controlled trials to be no better than a prior or lesser standard of care. Of almost 400 medical reversals identified through their review of RCTs published in three leading international medical journals, 23 (6%) and 3 (1%) were in orthopedics and rheumatology, respectively. Ten of these medical reversals included 1) acetaminophen is ineffective for treatment of acute low back pain, 2) a comprehensive exercise program was not better than a one-time consultation with a physiotherapist for relieving chronic neck pain due to whiplash, 3) neither diclofenac nor spinal manipulative therapy were effective for pain relief in patients with acute low back pain who had seen their primary care provider and been given acetaminophen (see #1 above), 4) radiofrequency denervation was no more effective than a standard exercise program in patients with chronic low back pain, 5) home-based rehabilitation was as effective as inpatient rehabilitation in improving mobility after total knee arthroplasty in patients with osteoarthritis, 6) surgical repair was not more effective than nonsurgical management of acute proximal humeral fractures in older adults, 7) neither cyclobenzaprine nor the combination of acetaminophen with oxycodone was more effective than placebo for treating acute low back pain when added to naproxen, 8) physical therapy did not improve pain or function more than sham therapy in patients with hip osteoarthritis, 9) hydroxychloroquine did not improve symptoms of eye dryness, fatigue or pain compared to placebo in patients with Sjogren syndrome, and 10) neither the addition of calcium nor vitamin D reduced the risk of new fractures in older adults who had sustained a low-trauma osteoporotic fracture. The authors suggest that de-adoption of these and other low-value practices would lead to improvements in medical care as well as cost savings.
Finally, I wish the incoming President, Dr. Matthew Dobbs, success in his tenure in guiding USBJI to fulfill its mission of raising the priority of musculoskeletal health through the collective action of all its stakeholders.