Hundreds more medical reversals. But not ISO accreditation

Herrera-Perez et al reviewed over 3000 randomized controlled clinical trials in leading medical journals.  They found 396 reversals of practice were indicated.

While medical leaders increasingly put their trust in ISO 15189 and ISO 17025 there remains a lack of evidence in the peer-reviewed journals whether it leads to improvement or harm.

The evidence is in the popular news and at Oxebridge that accreditation is no security against harm and is often a source of it.

It looks like there may be a long delay before the ISO accreditation fad has to be reversed.

Meta-Research: A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals

Feature Article
Cite this article as: eLife 2019;8:e45183 doi: 10.7554/eLife.45183



The ability to identify medical reversals and other low-value medical practices is an essential prerequisite for efforts to reduce spending on such practices. Through an analysis of more than 3000 randomized controlled trials (RCTs) published in three leading medical journals (the Journal of the American Medical Association, the Lancet, and the New England Journal of Medicine), we have identified 396 medical reversals. Most of the studies (92%) were conducted on populations in high-income countries, cardiovascular disease was the most common medical category (20%), and medication was the most common type of intervention (33%).


Low-value medical practices are medical practices that are either ineffective or that cost more than other options but only offer similar effectiveness (Prasad et al., 2013; Prasad et al., 2011Schpero, 2014). Such practices can result in physical and emotional harm, undermine public trust in medicine, and have both an opportunity cost (Korenstein et al., 2018) and a financial cost (Reid et al., 2016; Beaudin-Seiler, 2016). Identifying and eliminating low-value medical practices will, therefore, reduce costs and improve care.

Medical reversals are a subset of low-value medical practices and are defined as practices that have been found, through randomized controlled trials, to be no better than a prior or lesser standard of care (Prasad et al., 2013; Prasad et al., 2011). It can, however, be difficult to identify medical reversals. For example, Cochrane reviews provide high-quality evidence on medical practices (Garner et al., 2013), but each review focuses on only one practice and many practices have not been reviewed by Cochrane. The Choosing Wisely initiative in the US maintains a list of low-value medical practices, but it relies on medical organizations to report such practices and often includes only those practices where there is a high degree of consensus (Beaudin-Seiler, 2016).

Here we report how a systematic search of randomized controlled trials in three leading medical journals – the Journal of the American Medical Association (JAMA), the Lancet, and the New England Journal of Medicine (NEJM) – identified 396 medical reversals. It is our hope that, by building on previous efforts in this area (Prasad et al., 2013), this list will help others to eliminate the use of these practices…

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