http://www.medscape.com/MedscapeWire/2001/10/medwire.1011.mri.html

October 11, 2001

New York - Physicians surveyed about the most important innovations of the last 25 years ranked interventions for cardiovascular disease and high-tech scanning devices such as magnetic resonance imaging (MRI) and computed tomagraphy (CT) among the most important. They ranked bone marrow transplantation and the erectile dysfunction drug sildenafil among the least important innovations.

"This is the first study to look at the relative value to patients of different medical innovations, as judged by leading general internists actively involved in patient care," said Victor R. Fuchs, PhD, professor emeritus at Stanford University in California and a noted healthcare economist. Fuchs coauthored the study with Harold C. Sox Jr, MD, former chair of the Department of Medicine at Dartmouth and current editor of Annals of Internal Medicine.

In the study, 225 general internists from around the country were asked to review a list of 30 innovations and select 5 to 7 that would have the most adverse effect on their patients if these technologies did not exist, as well as the 5 to 7 that would have the least adverse effect. Among the innovations listed were laparoscopic surgery, ultrasonography, and coronary artery bypass. The result was a ranking of the 30 innovations based on the physicians' ratings.

The study appears in the September/October issue of the journal Health Affairs in a special section titled, "The Value of Innovation."

Fuchs said the study results may have far-reaching implications for evaluating physician practice style, expanding the critera for quality assessment and shifting the allocation of research and development funds. He said the most surprising finding was "the extent to which the leading innovations were an outgrowth of the physical sciences (physics, engineering, and computer science) rather than disciplines traditionally associated with the biomedical sciences."

He noted that there was a high degree of consensus in the rankings. Physicians' assessments were largely similar regardless of geographic location or type of practice. On average, diagnostic and surgical procedures were ranked significantly higher than medications. Fuchs said the internists' high rankings for procedures and lower rankings for medications were somewhat unexpected given that internists are "in the business of prescribing medications." He speculated that because one of the biggest problems in medicine is dealing with uncertainty, physicians place high value on innovations such as diagnostic procedures that help relieve that uncertainty.

A few innovations elicited considerable variability in response. HIV testing and treatment, cataract extraction, and a test for prostate cancer were among the most variable. The authors found that this variability was mainly due to differences in patient mix. For example, physicians who saw a large percentage of Medicaid patients in their practices gave HIV testing and treatment a higher-than-average score, while physicians who saw a large percentage of patients aged 65 years and older tended to give cataract extraction and lens implantations a higher-than-average score.

The 30 innovations were chosen based on the frequency with which they appeared as the principal focus of articles published in The Journal of the American Medical Association and the New England Journal of Medicine in the past 25 years. The 225 physicians surveyed were chosen for the length and breadth of their experience, distinction among their peers, and active involvement in patient care. Physicians who graduated from medical school after 1980 were excluded, as were those who spent less than half their time in face-to-face patient care. Because of this, Fuchs said, the survey population was not representative of all primary care physicians in the United States.

Fuchs said this study might provide an impetus for further research aimed at understanding the socioeconomic factors that contribute to the perceived value of innovations and ultimately lead to changes in health policy. The study was funded by the Robert Wood Johnson and Henry J. Kaiser Family Foundations.

The ranking of the 30 medical innovations in the study are as follows:

1. MRI and CT
2. ACE inhibitors
3. Balloon angioplasty
4. Statins
5. Mammography
6. Coronary artery bypass graft
7. Proton pump inhibitors and H2 blockers
8. Selective serotonin reuptake inhibitors (SSRIs) and new non-SSRI antidepressants
9. Cataract extraction and lens implant
10. Hip and knee replacement
11. Ultrasonography and echocardiography
12. Gastrointestinal endoscopy
13. Inhaled steroids for asthma
14. Laparoscopic surgery
15. Nonsteroidal anti-inflammatory drugs and COX-2 inhibitors
16. Cardiac enzymes
17. Fluoroquinolones
18. New hypoglycemic agents
19. HIV testing and treatment
20. Tamoxifen
21. Prostate-specific antigen testing
22. Long-acting and local opioid anesthetics
23. Helicobacter pylori testing and treatment
24. Bone densitometry
25. Third-generation cephalosporins
26. Calcium channel blockers
27. Intravenous conscious sedation
28. Sildenafil (Viagra)
29. Nonsedating antihistamines
30. Bone marrow transplant