Evidence based de-implementation. Should we stop some of what we are doing?
Over the past few months, I have made a real effort to read the general literature on evidence based care. I came across this very interesting paper concerned with the re-evaluation of the evidence underpinning established clinical practice. It was written by Vinay Prasad and John Ioannidis, who is rapidly becoming one of my heroes with his critical viewpoints on healthcare. I found that this paper was very relevant to all health care provision and I have decided to look at this from an orthodontist’s point of view.
Vinay Prasad and John Ioannidis
Implementation Science 2014: 9:!
http://www.implementationscience.com/content/9/1/1 This is an open access paper.
In the paper they raise this very good question
“Should we continue with healthcare practices that are established that do not have an evidence base?”
They specifically base the article around three main types of healthcare intervention.
- Those that are known not to work when RCTs have been carried out
- Those for which the evidence base is uncertain
- Those that are in development
Where do we stand on these issues for orthodontic treatment?
Evidence contradicts established practice
This concerns treatment where the best evidence shows no efficacy or the harms outweigh the benefits. I felt that the best orthodontic example was attempting to achieve orthopaedic or skeletal change. The evidence that we now have suggest strongly that we cannot change the young person’s skeletal pattern with functional appliances or headgear. Yet we continue to attempt this change. For example, if we consider functional appliances. We know that functional appliances tip teeth effectively and we routinely achieve good results in those patients whose skeletal discrepancy is not severe. However, in the child with a severe skeletal discrepancy should we still provide treatment with functional appliances or should we provide surgery, more effectively, when they are older? I have frequently attempted to treat severe skeletal II case in adolescence but I do also wonder if providing surgery would have been the best option. Where is the harm? Potentially this is an unnecessary course of treatment that introduces additional compensation which then needs correcting if and when orthognathic surgery is considered. As for headgear, there is no evidence to underpin that it causes skeletal change and the potential harms certainly outweighs any potential benefits.
The evidence base is uncertain
The best example I could put forward here was the extraction of primary canines to encourage the eruption of palatally placed permanent canines. The best evidence that we have on this procedure has been developed from a systematic review on the extraction of primary canines. This concluded that there was no evidence to underpin this type of treatment. This is because previous studies were carried out with no control , for example the classic paper by Ericsson and Kurol. In other papers that they considered there were issues with steady design that the authors could not clarify. While I appreciate that this absence of of evidence does not mean lack of effect. Nevertheless our practice, in this area, is still relying on poor quality evidence. Does this do harm? Some would argue that the removal of primary canines is “no big deal”. However, this is still an unnecessary surgical procedure for a young child.
Novel medical practice
This is a reflection of the fact that there is pressure on us to adopt new methods because we inherently feel that “new” must be “better”. In this respect, the most obvious orthodontic examples are temporary anchorage devices and self ligating brackets. For both of these treatments trials are currently underway and several of them have reported. If we consider temporary anchorage devices the reports of trials are looking interesting. It appears that temporary anchorage devices have similar effectiveness to headgear. Indeed they may be the preferred option, when you consider the potentially harmful effects of headgear. These findings are due to be reported in an updated systematic review that we are shortly to publish
But… Self legation is different. We now know that this type of bracket is no more effective than conventional brackets. But has harm being caused? The main concern is the adoption of expansion as part of the unfounded “philosophy” of treatment with sell ligating brackets. Only time will tell… Nevertheless, there is are surprisingly limited moves to “de-implement these brackets”, in spite of the evidence. Indeed the advertising is so powerful and notably non of the “advocates” have even challenged the research evidence.
What can we conclude?
In conclusion I am simply going to quote the conclusion of the paper because it is completely relevant to orthodontic care, and I cannot put it better.
“De-implementing practices reflect a recommitment to evidence-based health care. This is important for all treatments and any other intervention undertaken by people in the health professions. Strategies to eliminate a defective and harmful practice may help contain health-care spending and optimise outcomes. Ideally, the majority of medical decisions should be supported by robust data, with ambiguous decisions made only within the confines of ongoing studies. However, rational quantitative evidence may not necessarily be the only or even main factor driving health care decisions. Research to understand better the other cognitive or political factors that facilitate or hindered the implementation is thus also wanted”.
This is our challenge…
Vinay Prasad, & John Ioannidis (2014). Evidence based de-implementation for contradicted, unproven and aspiring healthcare practices. Implementation Science, 9 (1) DOI: 10.1186/1748-5908-9-1