FISCAL

Why is this initiative needed?
Health care is a force for good, but it can be overused, underused and misused. Increasing evidence from around the world shows that overdiagnosis, overtreatment, and overuse of medical treatments all have the potential to harm, but this harm has currently been largely ignored.^{1 2}

Abandoning ineffective medical practices and mitigating the risks of untested practices are crucial for improving patient health and containing healthcare costs³. It has been estimated that at least one third (1/3) of current medical expenditure in the US is ineffective or unnecessary.⁴  Equally importantly, important new research findings often go unnoticed and fail to elicit changes in clinical practice (Figure below).

What is the primary objective of the FISCAL Initiative?
The FISCAL Initiative aims to shift the emphasis of healthcare toward improved decision-making and principles of evidence-based medicine to counteract systemic biases favouring entrenched practices in the face of reliable scientific evidence.⁵

Where are we now?
So far, we have two primary FISCAL projects:

1) Placebo-surgery controlled trials; a series of trials assessing the efficacy of some of the most common orthopaedic procedures (read more).

2) FIASCO – Is the current – osteoporosis-based – strategy for prevention of fractures viable?; a series of critical, evidence-based analyses drilling into the current practices on how people with osteoporosis or at risk of sustaining an “osteoporotic” fracture are diagnosed and treated (read more).

1. Brodersen J, Kramer BS, Macdonald H, Schwartz LM, Woloshin S. Focusing on overdiagnosis as a driver of too much medicine. BMJ. 2018 Aug 17;362:k3494. doi: 10.1136/bmj.k3494.
2. Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world. Lancet 2017;390(10090):156-68. doi: 10.1016/S0140-6736(16)32585-5
3. Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA 2012;307(1):37-8. doi: 10.1001/jama.2011.1960
4. Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019 Oct 7. doi: 10.1001/jama.2019.13978.
5. Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci 2014;9:1. doi: 10.1186/1748-5908-9-1