Faded Promises: The Challenge of Deadopting Low-Value Care

We have a hard time changing what we do in medicine. Even after new treatments are shown to be effective, they are not suddenly embraced but are usually adopted in stagesfirst by the innovators, then the early adopters, and only over time by the laggards (1). However, deadoption may be even slower. As hard as it seems to get people to adopt new practices, a pervasive asymmetry in human psychology makes it even harder for them to give up old clinical practices that they have come to believe in, even when new evidence reveals that those practices offer little value. Examples In 2008, the U.S. Food and Drug Administration gave accelerated approval to bevacizumab (Avastin, Genentech, San Francisco, California) for metastatic breast cancer on the basis of preliminary findings that it increased progression-free survival by 5.5 months. However, data published in the coming years that were expected to confirm an overall survival benefit told the opposite story: Not only did the drug not extend life, it caused life-threatening adverse events. The U.S. Food and Drug Administration thus withdrew its provisional approval in 2011. Patients and oncologists reacted strongly, arguing that for some women, the decision was a death sentence (2). In 2012, the U.S. Preventive Services Task Force recommended against routine prostate-specific antigen screening, citing greater harm than previously recognized in the form of unnecessary biopsies, treatments, and adverse effects compared with the small number of lives saved. The decision prompted an outcry from patients and physician groups. Both examples follow a pattern: The clinical practice is endorsed and in use, so we start from the position of accepting its potential benefits. New evidence reveals that its initial promise was false, but this information does not change our positive outlook. The central point is that we seem more willing to adopt something by virtue of its promise than we are to abandon it once that promise has faded. Biases Although the financial interests of stakeholders may slow deadoption, those financial interests cannot be the whole story and, in any event, would not explain asymmetries between adoption and deadoption. Instead, several psychological forces are probably at play. One is optimism bias, which is a tendency for people to be more willing to accept new information in their favor than out of it (3). Closely related is confirmation bias, which is the tendency for people to favor information that confirms prior beliefs (4). A third is loss aversion, which is the tendency for people to feel more strongly about losses than they feel about similarly sized gains (5). A fourth is the affect heuristic, whereby our initial feelings about somethinggood or badcontinue to color our judgment of its risks and benefits (6). Whether these processes are working alone or together, they help explain why reducing the use of low-value health care services is so hard and why the task fundamentally differs from the related one of increasing the use of high-value services. Consequences This asymmetry may have psychological roots, but it has clinical and financial consequences. Once bevacizumab entered the National Comprehensive Cancer Network Drugs & Biologics Compendium, it was never removed. The result is that, for patients covered by the Centers for Medicare & Medicaid Services and most patients covered by private insurance, bevacizumab is required to be reimbursed for metastatic breast cancer and therefore is still widely used. Backtracking on prostate-specific antigen testing has been no easier. In a 2011 survey of 1089 men without prostate cancer, 62% of respondents agreed with the new U.S. Preventive Services Task Force recommendation and 69% believed that it was based on the latest research. However, only 13% of respondents intended to follow the advice; 54% planned to be tested anyway, and 33% were undecided (7). Approaches One important lesson of behavioral economics is that this kind of asymmetry should be expected. Although traditional economists see the world through the eyes of rational beings who view gains and losses as mirror images, behavioral economists see the world through the eyes of fallible humans who mourn losses more than they celebrate gains. However, behavioral economists also teach us to use the knowledge of our asymmetrical thinking to improve our decisions, as if using corrective prisms to adjust for distortions in human vision. For low-value care that is already entrenched, lessening the perceived loss when this care is subsequently withheld or taken away may be possible. For example, the Choosing Wisely campaign suggests discussing with one's physician the benefit of a service rather than its lack of benefit. Such framing may be a softer and therefore more effective way to shift our sense of potential value downward and combat the optimistic perspective that may leave us less willing to budge. A more effective approach may be to prevent the problem of asymmetry entirely by keeping low-value services from becoming entrenched. The Centers for Medicare & Medicaid Services' Coverage with Evidence Development and the U.S. Food and Drug Administration's accelerated approval programs attempt this by providing only temporary approval, but even they are subject to the same asymmetry that occurred with bevacizumab. The solution may be to plan for the psychological challenge of withdrawal by explicitly influencing the reference point from the start. Physicians are accustomed to hanging crepe with their patientspromoting a pessimistic reference point so that most later news will be seen as good (8). Perhaps we need to enforce a similarly less-positive stance with all new approaches at risk for being withdrawn, with precautions not to discourage appropriate medical care. For example, the loss of provisional use of bevacizumab may have stung less than the loss of accelerated approval. These approaches may seem like empty manipulations, but they follow the same real behavioral pathways as the forces that make us resist giving up low-value services in the first place. The challenge of reducing low-value care is partly about clinical medicine and social benefit, but it is also about perception. As a result, we should look to the psychology behind those perceptions for some of our responses.