Faded Promises: The Challenge of Deadopting Low-Value Care
Authors: Benjamin R. Roman, David A. Asch
Journal: Annals of Internal Medicine (2014)

Ideas and Opinions15 July 2014Faded Promises: The Challenge of Deadopting Low-Value CareBenjamin R. Roman, MD and David A. Asch, MD, MBABenjamin R. Roman, MDFrom the Robert Wood Johnson Foundation Clinical Scholars Program and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, and Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York. and David A. Asch, MD, MBAFrom the Robert Wood Johnson Foundation Clinical Scholars Program and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, and Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M14-0212 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail 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 stages—first 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. ExamplesIn 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.BiasesAlthough 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 something—good or bad—continue 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.ConsequencesThis 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).ApproachesOne 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 patients—promoting 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.References1. Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Pr; 2003. Google Scholar2. Pollack A. F.D.A. revokes approval of Avastin for use as breast cancer drug. The New York Times. 19 November 2011:B1. Accessed at www.nytimes.com/2011/11/19/business/fda-revokes-approval-of-avastin-as-breast-cancer-drug.html on 28 February 2014. Google Scholar3. Weinstein ND. Unrealistic optimism about future life events. J Pers Soc Psychol. 1980;39:806-20. CrossrefGoogle Scholar4. Jonas E, Schulz-Hardt S, Frey D, Thelen N. Confirmation bias in sequential information search after preliminary decisions: an expansion of dissonance theoretical research on selective exposure to information. J Pers Soc Psychol. 2001;80:557-71. [PMID: 11316221] CrossrefMedlineGoogle Scholar5. Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk. Econometrica. 1979;47:263-91. CrossrefGoogle Scholar6. Finucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. J Behav Decis Mak. 2000;13:1-17. CrossrefGoogle Scholar7. Squiers LB, Bann CM, Dolina SE, Tzeng J, McCormack L, Kamerow D. Prostate-specific antigen testing: men's responses to 2012 recommendation against screening. Am J Prev Med. 2013;45:182-9. [PMID: 23867025] CrossrefMedlineGoogle Scholar8. Siegler M. Pascal's wager and the hanging of crepe. N Engl J Med. 1975;293:853-7. [PMID: 1177976] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Benjamin R. Roman, MD, MSHP, David A. Asch, MD, MBAUniversity of Pennsylvania27 August 2014 Author's Response We agree with Dr. Schwartz that high costs have many origins. However, our main point was that addressing medical overuse will require more than just setting new standards of appropriateness and providing education and guidance toward those standards. Our difficulty giving up low value services arises less because physicians might be self-interested or socialized toward the wrong goals, and more because physicians are human, and susceptible to characteristically human errors in thinking. These include optimism bias, confirmation bias, loss aversion, the affect heuristic, and perhaps other decision processes that are not the products of reason but reflections of our psychological foibles. By all means, let's teach and socialize our physicians toward economically prudent care. Let's recast professional standards to include value. But unless we also acknowledge and learn to circumvent our deeply seated psychological biases we shouldn't expect any of these approaches to get us much closer to our goals. Frederic H. Schwartz, MD, FACP University of Massachusetts School of Medicine 25 July 2014 Comment I read Drs. Roman and Asch's article with great interest and wish to share my perspective on runaway health care costs and their sources with the Internal Medicine community. While psychological forces may be at play in the deadoption process of chemotherapeutic agents, procedures and technologies, I do not believe this to be a significant factor in causing runaway costs. Rather the major etiology is the pervading culture that emanates from what Arnold Relman, MD described as the "medical industrial complex". The American College of Physicians has taken a bold and important initiative with their new emphasis on introducing value training for graduate trainees in Internal Medicine. Unfortunately, the problem begins in medical schools where students are seduced by the lures found within the hollowed walls of technology and cutting edge procedures. I believe that the Hippocratic Oath needs to be reworked to include the necessity of always striving to provide patient care in the most cost effective way possible with the goal of providing the "greatest good for the greatest number". It needs to be emphasized that providing "cost effective" and medically appropriate care for patients is as important as having compassion for patients and their families, acquiring the necessary training and expertise, continuing medical education and being leaders of the health care team. It is imperative that this new culture is adopted not just by primary care physicians but by specialists as well. Medical students, physician assistant students, nurse practitioner students, interns, residents, and fellows must learn that they are being judged by their mentors and teachers not only by their ability to perform a procedure but also by having the skill to know when and why that procedure is medically appropriate. For example, when I trained in the mid 1980s it was almost de rigeur to order as many tests as one could think of when working up a patient for an undiagnosed illness. Think of the elderly patient with dementia who is seen by a neurologist who orders a HIV, Lyme, RPR, ANA, ESR, EEG and MRI. No wonder that gynecologists were able to promote unnecessary annual check ups (including PAP smears) for years. The public has been convinced that more is better and a sign of caring by the physician when the reality is that physician's motivation was often based on what was best for their business and bottom line. I will never forget reading in the Annals in the late 1980s that PAP smears in the average risk woman can be safely spaced three years apart assuming they are normal each time and then experiencing the real world where woman were typically receiving PAP smears on an annual basis even when they did not have cervixes. Until the medical community chooses to add "cost effective care" as one its core values for all specialties, the United States will continue to lead the world in health care costs per capita. Unfortunately, as we all know, spending the most has not, and never will, translate to providing the highest quality care. Author, Article, and Disclosure InformationAffiliations: From the Robert Wood Johnson Foundation Clinical Scholars Program and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, and Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York.Acknowledgment: The authors thank Peter Bach, Jon Baron, Jack Hershey, George Loewenstein, and Victor Fuchs for providing valuable comments about earlier versions of this manuscript.Financial Support: In part by the Robert Wood Johnson Foundation Clinical Scholars Program.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0212.Corresponding Author: David A. Asch, MD, MBA, Blockley Hall 1123, 423 Guardian Drive, Philadelphia, PA 19104; e-mail, [email protected]upenn.edu.Current Author Addresses: Dr. Roman: Blockley Hall 1303, 423 Guardian Drive, Philadelphia, PA 19104.Dr. Asch: Blockley Hall 1123, 423 Guardian Drive, Philadelphia, PA 19104.Author Contributions:Conception and design: B.R. Roman, D.A. Asch.Analysis and interpretation of the data: B.R. Roman, D.A. Asch.Drafting of the article: B.R. Roman, D.A. Asch.Critical revision of the article for important intellectual content: B.R. Roman, D.A. Asch.Final approval of the article: B.R. Roman, D.A. Asch.Administrative, technical, or logistic support: B.R. Roman, D.A. Asch.Collection and assembly of data: B.R. Roman, D.A. Asch.This article was published online first at www.annals.org on 29 April 2014. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Challenge of Deadopting Low-Value Care Frederic H. 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Schwartz, MDThe 2009 American Thyroid Association Guidelines Modestly Reduced Radioactive Iodine Use for Thyroid Cancers Less Than 1 cm 15 July 2014Volume 161, Issue 2Page: 149-150KeywordsAntigensBreast cancerDisclosureMedical servicesMedicarePerceptionProstate cancerPsychologyVision ePublished: 15 July 2014 Issue Published: 15 July 2014 Copyright & PermissionsCopyright © 2014 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...