CAN CONTRAINDICATIONS COMPROMISE EVIDENCE-BASED, PATIENT- CENTERED CLINICAL PRACTICE?

Abstract

Background

Despite their often weak evidence base, contraindications convey the unequivocally adverse risk-benefit profile of an intervention in a specific clinical context. However, some patients in that context may nonetheless prefer the contraindicated intervention (with its potential benefits and risks) to the available alternatives. The impact of contraindications on treatment decisions remains unexplored.

 Objective

To provide an estimate of the impact of the “contraindication” label on treatment decisions.

 Methods

We conducted an international 6-wave email/internet and fax survey of practicing clinicians who were members of the American Diabetes Association or the College of Physicians and Surgeons of Ontario and had available email addresses and fax numbers. Each participant considered one of two patient scenarios. In  each scenario, the  patient  expressed a  strong preference for  use  of  a  medication that  carried a “contraindication” label despite weak evidence of harm. We designed these scenarios so that respondents who placed greater weight on patient preferences and research evidence than on the label “contraindication” would  be  ready  to  prescribe the  contraindicated medication.  We  determined the frequency with which the label “contraindication” dominated participants’ treatment decisions despite patient preferences and weak evidence of harm.

 Results

466 participants responded (22% response rate). Depending on the group and scenario, contraindications dominated the decisions of 47% to 89% of surveyed clinicians, superseding patient preferences and research evidence.

 Conclusions

The label “contraindication” may often dominate clinicians’ decisions about treatment and may compromise evidence-based, patient-centered clinical  practice. Further research should elucidate  the process that leads to the formulation of contraindications and its impact on treatment decision-making.