Americans idolize technology and crave innovation. Whether in cars, electronics, or health care, US consumers willingly pay more for new products and new methods because they believe that "new" is better that "old." Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises by Richard A. Deyo, MD, MPH and Donald L. Patrick, PhD, MSPH challenges this belief. These two University of Washington professors contend that our culture's unquestioning confidence in medical technology and innovation boosts health care costs and, at times, threatens our health. Unlike people in other developed countries, we in the US tend to ignore social or environmental solutions to health problems. Instead of improving air and water quality or making lifestyle changes, we look for the newest drug or supplement, the latest medical device, or a "breakthrough" surgical procedure to heal our bodies. All too often, these new interventions fail to live up to the hype; yet they drive the cost of health care ever higher. Hope or Hype details how our love affair with innovation combined with relentless advertising, skewed research, greed, and holes in government "safety nets" contribute to a dismal fact: Even though the US spends more on health care than any other country, we have "shorter longevity, worse public health statistics, and worse health-care inflation than most developed nations."

Throughout Hope or Hype, Deyo and Patrick give examples of drugs, devices, treatments, and medical tests that have not lived up to expectations. Medical tests can greatly increase medical cost, not only because of the cost of the medical test itself but also because an abnormal result on one test often leads to more tests. No test is completely reliable. False negatives (i.e., something is wrong but the test indicates no problem) and false positives (i.e., nothing is wrong but the test says that there is) are common. Deyo and Patrick tell readers, "When you get tests for no good reason--such as signs or symptoms of illness--abnormal results are far more likely to be false positives than if the test is done because of suggestive symptoms or exam findings ... It's a consequence of the fact that no test is perfect: There are always some false positives and false negatives."

Accurate test results do not mean that an effective treatment will follow. Many clinical trials measure surrogate outcomes, such as lowering cholesterol or shrinking tumors, in place of a primary outcome, such as longevity. In many cases, however, a positive surrogate outcome does not mean that people will live longer. Deyo and Patrick say, "... a long and growing list of counterexamples makes it important to focus on the outcome that is of real interest. Drugs that lower cholesterol or normalize heart rhythm have sometimes paradoxically increased mortality, and tumor shrinkage is a notoriously poor indicator of real benefit."

To gain FDA approval, a new drug or medical device merely needs to show that it is more effective than a placebo. The heavily advertised antihistamine Claritin, for example, is just 11% more effective in reducing symptoms than a placebo (sugar pill), according to a clinical trial (J Allergy Clin Immunol 1989; 84(5 Pt 1): 741-746). While new drugs must be better than a placebo to gain approval, the FDA does not require comparative studies that show their effectiveness in relation to other products on the market. Standards for approving medical devices are less rigorous than those for approving drugs, and new surgical procedures do not have to undergo any approval process at all.

All the drug lobbying and advertising and manipulated research studies and free samples and sales promotions would have less impact if news media held more skepticism about medical innovations. Unfortunately, reporters too often add to the hype at the expense of accuracy. In a study from Loma Linda VA Medical Center and School of Medicine, two independent evaluators checked the accuracy of 587 articles from major newspapers and magazines. One-third of these articles (32%) contained inaccurate or misleading information. Statistics found in news reports can be particularly misleading. As an example, Deyo and Patrick refer to a 1996 study about Fosamax that received airtime on ABC, CBS, and NBC news programs: "All three networks reported that the osteoporosis drug reduced the risk of hip fractures by 50%, which one reporter described as 'almost miraculous.' This was the relative risk reduction. None reported the absolute risk of fracture, which was two percent in untreated women and one percent in treated women. Going from two percent to one percent is a 50% relative reduction, of course, but many viewers would find the one percent absolute difference in risk less impressive."

To counter the hype generated by industry and news media, Deyo and Patrick advocate the use of decision aids. Decision aids, based on randomized trials, let patients evaluate the risks and benefits of a treatment for themselves. Instead of merely listing all possible side effects, decision aids include the frequency of each side effect so that patients have a better understanding of the problems that they can face. Benefits are quantified in absolute terms rather than relative terms: "Instead of being told, for example, 'this drug will reduce your risk of stroke by 50%,' patients could see whether that meant from 40% to 20% or from one percent to 0.5%--both of which could be called 50% reductions." Studies have shown that patients who use decision aids often end up choosing more conservative, less technological treatment. Although such treatments are less expensive, they can work just as well as the newer ones. Deyo and Patrick say that trials evaluating the use of decision aids show that patients "who saw the decision aids had treatment results at least as good as those who didn't."

Hope or Hype encourages consumers to be skeptical about medical treatments--especially if a drug or device has been on the market less than a year. The authors explain how hype gets passed off as truth, and they give countless examples of drugs and treatments that do not live up their press. Deyo and Patrick also offer ways to counter false hype through decision aids and comparative research studies, funded by government and insurance companies. "The reality is," the authors state, "that most medical advances are incremental, and true breakthroughs are rare. Our hope is to inject some healthy skepticism into the way medical advances are received."

Every once in a while, I come upon a book that challenges the way I live and work and that changes my perceptions and actions. Hope or Hype is such a book. I highly recommend it.