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PubMed2006

The diffusion of medical technology, local conditions, and technology re-invention: a comparative case study on coronary stenting.

Innovation of medical technology is a major driving force behind the increase in medical expenditures in developed countries. Previous studies identified that the diffusion of medical technology varied across countries according to the characteristics of regulatory policy and payment systems. Based on Roger's diffusion of innovation theory, this study purported to see how local practice norms, the evolving nature of diffusing technology, and local clinical needs in addition to differences in politico-economic systems would affect the process of innovation diffusion. Taking a case of coronary stenting, an innovative therapeutic technology in early 1990s, we provided a case study of hospital-based data between two teaching high-tech hospitals in Japan and the US for discussion. Stenting began to be widely used in both countries when complementary new technology modified its clinical efficacy, but the diffusion process still differed between the two hospitals due to (1) distinctive payment systems for hospitals and physicians, (2) practice norms in favor of percutaneous intervention rather than bypass surgery that was shaped by payment incentives and cultural attitudes, and (3) local patient's clinical characteristics that the technology had to be tailored for. The case study described the diffusion of stent technology as a dynamic process between patients, physicians, hospitals, health care systems, and technology under global and local conditions.

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PubMed2003

A multihospital safety improvement effort and the dissemination of new knowledge.

BACKGROUND: Research on the transfer of medical technology and guidelines suggests that this transfer is driven more by interpersonal relationships than by new research or available information and that it is inconsistent, largely unsuccessful, and strongly influenced by local factors. Yet studies of collaborative, multiple-hospital improvement efforts have shown these transfers to be effective for the specific microsystems participating in the project. The diffusion of medical innovations beyond the participating teams was studied during a 2000-2001 national collaborative safety improvement effort. METHODS: Twenty-two teams from Department of Veterans Affairs (VA) hospitals participated in a 9-month quality improvement project designed to improve safety in high-hazard areas. Participating hospitals and other regional hospitals were contacted to determine the level of dissemination of information generated during and after the project. RESULTS: While the participating hospitals benefited from the quality improvement effort, changes were implemented only 9% of the time on other units within the hospitals and only 2% of the time in other regional hospitals. After 12 months, there was no implementation within participating hospitals, and other regional hospitals were implementing changes 10% of the time. DISCUSSION: Personal commitment from senior leadership, dissemination strategies that push information to clinicians, and monitoring of progress at the regional level are all needed for dissemination of complex medical information to occur.

Cooperative Behavior↗

PubMed2003

Temporal trends in radical prostatectomy complications from 1991 to 1998.

PURPOSE: We performed a retrospective, longitudinal, population based study to ascertain whether radical prostatectomy outcomes improved after the diffusion of surgical innovations during the last decade. MATERIALS AND METHODS: Using a 5% national random sample of Medicare beneficiaries we identified 12,079 men who underwent radical prostatectomy from 1991 to 1998. We analyzed relevant Medicare data to establish length of stay and the rate of in hospital complications (cardiac, respiratory, vascular, wound and genitourinary conditions) as well as the rate of anastomotic stricture, incontinence and impotence through 36 months after surgery. We performed multivariate logistic regression to control for age, race and geographic region when assessing the association of surgery year with outcomes of interest. RESULTS: Between 1991 and 1998 the in hospital complication rate decreased from 38% to 30% and mean length of stay decreased from 8.1 to 5.1 days. Each value had significant regional variation throughout the United States. The 3-year incontinence rate decreased from 20% in 1991 to 4% in 1995. However, no meaningful trends were observed in the rate of impotence, anastomotic stricture, or placement of artificial urinary sphincters or penile prostheses. On multivariate analysis, older age (75 years or older, OR 1.68, p <0.01) and nonwhite race (OR 1.35, p <0.01) were associated with more in hospital complications. Nonwhite patients were also more likely to be diagnosed with impotence (OR 1.25, p <0.01) and undergo penile prosthesis placement (OR 1.5, p <0.01). CONCLUSIONS: As urologists reach consensus on the ideal clinical characteristics for radical prostatectomy candidates, surgery in fewer elderly patients and the dissemination of surgical advances have been associated with shorter length of stay, fewer in hospital complications and a lower long-term incontinence rate. However, there is capacity for improvement, as evidenced by the unchanging rate of anastomotic stricture and impotence.

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PubMed1998

Responsibility for clinical innovation. A case study in neonatal medicine.

Proper evaluation of clinical innovations and of the process of their diffusion is essential for the development of sound health care policy. This case study examines transcutaneous oxygen monitoring in neonatal intensive care, a procedure that was rapidly adopted in the late 1970s as a scientific breakthrough of great promise, then all but abandoned within a decade in favor of pulse oximetry, a still more recent technology. The study incorporates the results of interviews with representatives of industry as well as biomedical researchers and clinicians involved with these devices. Factors in technology diffusion are analyzed, with special attention to those susceptible to change by policy makers. Participants in the diffusion process also include nurses, hospital administrators, the legal profession, the news media, and the public, but the pivotal role--and hence ultimate responsibility--is seen to be that of the physician. The discussion is presented in the context of a proposed "ethics of evidence" pertinent to medical decision making.

Attitude of Health Personnel↗

PubMed2003