Older Doctors Less Likely to Abandon Ineffective Therapies

Older Doctors Less Likely to Abandon Ineffective Therapies

Research Cites 'Cognitive Inertia' and Tendency to Rely on Familiar Assumptions

David Howard
David H. Howard, PhD, Professor of Health Policy and Management at Emory University's Rollins School for Public Health, spoke at an LDI Research Seminar.

Physicians' use of outdated or ineffective therapies has long been recognized as a major source of patient harm. In the era of health care reform, it's also become widely recognized as a major source of wasted money and a target at which scores of new clinical guidelines are aimed, from 2012's Choosing Wisely report to recommendations from the U.S. Preventive Services Task Force.

But how quick are physicians to abandon ineffective methods or adopt these new, evidence-based ones? It's a question of great interest to David Howard of Emory University's Rollins School of Public Health.

Older physicians' inertia
In a presentation entitled, "Inertia in Physicians' Practice Patterns," at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI), Howard detailed his latest study, demonstrating that older physicians are slower to abandon old and out-of-date practices.

Specifically, he looked at rates of episiotomy, a procedure used to facilitate childbirth that is no longer recommended for routine use. Because there is no medical or financial rationale for performing episiotomy in most instances, it is a case in which physicians' beliefs are likely to have a strong effect on their practice patterns.

Howard's data show that while the episiotomy rate has declined among physicians of all ages since the procedure began to fall out of favor, it remains significantly higher among older physicians. Contrary to the common assumption that more experience is better when it comes to choosing a physician, age and experience were associated with lower quality of care in his study.

The research suggests that cognitive inertia, or the tendency to rely on familiar assumptions and practices even in the face of new information, could be responsible for some of the lag in adoption of new clinical practices.

Lack of financial pressure
Part of the difficulty in getting doctors to abandon old practices like episiotomy, in contrast with promoting the implementation of new practices, is that the effort typically lacks financial backers.

"When pharmaceutical companies and medical device companies are coming out with a new product, they have a big incentive to make sure that doctors are up on the latest practices, so they sponsor continuing medical education and talks at professional societies," Howard said. "There's really nothing equivalent for instances where an existing treatment pattern or test doesn't work or isn't effective, so there's an asymmetry there."

While in cases in which a new guideline comes out definitively and universally against a particular treatment -- high-dose radiation breast cancer therapy, for example -- the medical community has shown itself able to comply quickly. Most recommendations, however, are less absolute, and nonspecific guidelines have been shown to contribute to a slower adoption process.

Adhering to clinical guidelines takes on new importance as hospital administrators and federal policymakers struggle to bring spending under control.

"When you think about where can we cut costs, one of the first places you look is at practices that don't benefit patients," Howard said. Continued use of expensive and out-of-favor procedures is therefore not just an issue of best medical practice, but also an issue that places a financial burden on the entire healthcare system.