University of Chicago professor and physician Adam Cifu had a similar experience. Cifu had spent several years convincing newly postmenopausal patients to go on hormone therapy for heart health—a treatment that at the millennium accounted for 90 million annual prescriptions—only to then see a well-designed trial show no heart benefit and perhaps even a risk of harm. "I had to basically run back all those decisions with women," he says. "And, boy, that really sticks with you, when you have patients saying, ‘But I thought you said this was the right thing.'" So he and Prasad coauthored a 2015 book, "Ending Medical Reversal," a call to raise the evidence bar for adopting new medical standards. "We have a culture where we reward discovery; we don't reward replication," Prasad says, referring to the process of retesting initial scientific findings to make sure they're valid.
Steven Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, says the situation with stents, at least, is improving. As a previous president of the American College of Cardiology, he helped create guidelines for determining when a stable patient might be a reasonable candidate for a stent. (Both Nissen and David Holmes, a Mayo Clinic cardiologist and also a former ACC president, said that in cases in which patients have had bad responses to medication and persistent, life-altering chest pain, even a short-term reduction of symptoms may justify a stent.) Thanks to such guidelines, the frequency of clearly inappropriate stent placement declined significantly between 2010 and 2014. Still, the latest assessment in more than 1,600 hospitals across the country concluded that about half of all stent placements in stable patients were either definitely or possibly inappropriate. "Things have gotten better," Nissen says, "but they're not where they need to be." Nissen thinks removing financial incentives can also help change behavior. "I have a dozen or so cardiologists, and they get the exact same salary whether they put in a stent or don't," Nissen says, "and I think that's made a difference and kept our rates of unnecessary procedures low."
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