Diffusion Of Medical Technology Research Articles

Health Technology Assessment (HTA) in a changing social and health care context

Health Technology Assessment (HTA) has been defined in different ways, nevertheless it can be described briefly as a multidisciplinary process of analysis dealing with evidence and context to inform decision making in health care. For decades HTA and related fields, aimed to produce and encourage the use of scientific evidence to inform decision making, at all levels of the health care system, from policy making and management to clinical decision making [1,2]. Scientific evidence involved in the HTA process may refer to efficacy, effectiveness, safety, needs, appropriateness, efficiency, equity, acceptability and some other issues related to the effect of the introduction, use and diffusion of medical technologies on health and health care. The evaluation, with formal rules, of the quality of a vailable scientific information is an important step of the HTA process as are the skills required for literature searching. The source of scientific information should not be limited to clinical literature, but also exploit other areas of knowledge such as epidemiology, social sciences,economics,health services research among others [1].The best method to be used in the HTA analysis process obviously depends on the uncertainties to be assessed. It could range from the synthesis and/or integration of scientific information to production of primary data.The latter is the option of choice when there is insufficient existing evidence or its quality is poor. The assessments often require a multidisciplinary and multi-method approach, the former, of course,must be chosen after translating the uncertainty into sound research questions.

Geographic diffusion of digital mammography in the United States.

Examining temporal and spatial diffusion of a new technology, such as digital mammography, can provide important insights into potential disparities associated with access to new medical technologies and how quickly these technologies are adopted. Although digital mammography is currently a standard technology in the United States for breast cancer screening, its adoption and geographic diffusion, as medical facilities transitioned from film to digital units, has not been explored well. This study evaluated the geographic diffusion of digital mammography facilities from 2001 to 2014 in the contiguous United States (excluding Alaska and Hawaii) and estimated the geographic accessibility to this new technology for women aged ≥45years at the census tract level within a 20-minute drivetime by population density, rural/urban residence, and race/ethnicity. The number of mammography units by technology type (film or digital) and density per 10,000 women were also summarized. The adoption of digital mammography advanced first in densely populated regions and last in remote rural areas. Overall, proportion of digital mammography units increased from 1.4% in 2001 to 94.6% in 2014, but since 2008, there was a decline in density of units from 2.31 per 10,000 women aged ≥45years to 1.97 in 2014. In 2014, approximately 87% of women aged ≥45years in the contiguous United States had accessibility to digital mammography, but this proportion was substantially lower for Native American women (67%) and rural residents (32%). Understanding the diffusion of and accessibility to digital mammography may help predict future medical technology diffusion and assess its role in geographic differences in cancer diagnosis and treatment.

Optimal Physician Shared-Patient Networks and the Diffusion of Medical Technologies.

Social network analysis has created a productive framework for the analysis of the histories of patient-physician interactions and physician collaboration. Notable is the construction of networks based on the data of "referral paths" - sequences of patient-specific temporally linked physician visits - in this case, culled from a large set of Medicare claims data in the United States. Network constructions depend on a range of choices regarding the underlying data. In this paper we introduce the use of a five-factor experiment that produces 80 distinct projections of the bipartite patient-physician mixing matrix to a unipartite physician network derived from the referral path data, which is further analyzed at the level of the 2,219 hospitals in the final analytic sample. We summarize the networks of physicians within a given hospital using a range of directed and undirected network features (quantities that summarize structural properties of the network such as its size, density, and reciprocity). The different projections and their underlying factors are evaluated in terms of the heterogeneity of the network features across the hospitals. We also evaluate the projections relative to their ability to improve the predictive accuracy of a model estimating a hospital's adoption of implantable cardiac defibrillators, a novel cardiac intervention. Because it optimizes the knowledge learned about the overall and interactive effects of the factors, we anticipate that the factorial design setting for network analysis may be useful more generally as a methodological advance in network analysis.

The diffusion of robotic surgery: Examining technology use in the English NHS

This paper examines the adoption and diffusion of medical technology as associated with the dramatic recent increase in the surgical use of robots. We consider specifically the sequential adoption and diffusion patterns of three interrelated surgical technologies within a single healthcare system (the English NHS): robotic, laparoscopic and open radical prostatectomy. Robotic and laparoscopic techniques are minimally invasive procedures with similar patient benefits, but the newer robotic technique requires a high initial investment cost to purchase the robot and carries high maintenance costs over time. Using data from a large UK administrative database, Hospital Episodes Statistics, for the period 2000–2018, we analyse 173 hospitals performing radical prostatectomy, the most prevalent and earliest surgical area of adoption of robotic surgery. Our empirical analysis first identifies substitution effects, with robotic surgery replacing the incumbent technology, including the recently diffused laparoscopic technology. We then quantify the spillover of robotic surgery as it diffuses to other surgical specialties. Finally, we perform time-to-event analysis at the hospital level to quantitatively examine the adoption. Results show that a higher number of urologists and a wealthier referral area favor robot adoption.

Barriers to the Diffusion of Medical Technologies Within Healthcare: A Systematic Review

Implementing medical devices into a clinical setting is a complex and lengthy process. Existing models, such as Rogers’ Diffusion of Innovation, try to elucidate this process, however, need to be updated to the evolving healthcare context as fewer than 7% of devices achieve implementation. The aim of this systematic review was to describe the barriers to diffusion in relation to this model to understand why so few technologies are implemented and how to address these challenges to mitigate risk during the translation process. To do this, we searched PubMed, Medline, and Embase databases for studies published between 01/01/1999 – 30/10/2019. Theoretical and application studies were included, and thematic analysis was employed using the Braun and Clarke framework to generate broad themes from the specific concepts described by included studies. A total of 33 articles were eligible for inclusion. Innovation processes constituting an obstacle to diffusion included: technology-specific challenges (8/33), clinical evidence/uncertainty (5/33), regulatory affairs (6/33), health technology assessment (7/33), reimbursement (15/33), and adoption (6/33). The factors that contributed to these themes were identified as being associated to the 11 tenets of Rogers’ Diffusion of Innovation. This allowed the discussion of the identified barriers to medical device diffusion in relation with the Rogers’ model. This analysis enabled the development and proposal of a framework that incorporates considerations within commercialization and translation strategies for these barriers to ultimately facilitate medical technology implementation.

Impact of Guidelines on the Diffusion of Medical Technology: A Case Study of Cardiac Resynchronization Therapy in the UK.

IntroductionResearch on clinical practice guidelines as a determinant of the diffusion of medical technology remains sparse. We aim to evaluate the impact of guidelines on the awareness of medical technology, as a proxy of its use, with the example of cardiac resynchronization therapy (CRT) in the United Kingdom (UK).MethodsWe measured clinician awareness based on Google searches performed for CRT that corresponded with actual CRT implant numbers provided by the European Heart Rhythm Association (EHRA). We identified the guideline recommendations published by the National Institute of Health and Care Excellence (NICE) within the UK, the European Society of Cardiology (ESC) at the European level, and the American College of Cardiology Foundation/American Heart Association in the United States (US). We specified a dynamic moving average model, with Google searches as the dependent variable and guideline changes as the independent variables.ResultsOne guideline change published by NICE in 2007 and two changes released by the US guidelines in 2005 and 2012 were significantly correlated with the Google searches (p = 0.08, p = 0.02, and p = 0.02, respectively). Guideline changes by the ESC had no significant impact. Changes recommending CRT in place of a conventional pacemaker, in patients with atrial fibrillation, and restricting CRT due to contraindication, remained universally uninfluential.ConclusionThe factors associated with a lack of awareness (as a proxy for technology diffusion) in our case study were: a lack of strong clinical evidence that resulted in the moderate strength of a recommendation, a lack of recognition of any externally published recommendation by NICE, and the frequent release of guidelines with minor changes targeting small patient groups. At least in our case, in the absence of NICE guidelines, the US guidelines received more attention than their non-UK European counterparts, even if the former were released after the latter.Electronic supplementary materialThe online version of this article (10.1007/s40258-020-00610-8) contains supplementary material, which is available to authorized users.

The medical arms race and its impact in Chinese hospitals: implications for health regulation and planning.

The rapid diffusion of medical technologies is widely recognized as a key driver of healthcare cost escalation. The excessive duplication of technologies gives rise to the so-called medical arms race. Conventional wisdom tends to explain this phenomenon by external reimbursement mechanisms and hospitals' competitive strategies, but has largely neglected the role played by health regulations that may also affect hospitals' technology adoption decisions. This study sheds new light on the medical arms race with evidence from China, which has witnessed an unprecedented expansion of big tertiary hospitals and a keen pursuit of expensive medical technologies. Chinese hospitals aggressively pursue high-tech medical equipment as an opportunistic reaction to the peculiar health regulatory environment. By analysing a panel dataset collected from Shenzhen City, this study reveals a series of important impacts of the medical arms race in Chinese public hospitals. High-tech medical equipment is found to lead to an increase in hospital revenues and patient volumes, but no significant impact is noted on unit costs. While high-tech medical equipment is associated with a discernible improvement in clinical outcomes, no contribution to hospitals' operational efficiency is noted. These findings are interpreted in the context of the broader health regulatory framework and China's public hospital reforms.

Diffusion of advanced medical imaging technology, CT, and MRI scanners, in Iran: A qualitative study of determinants.

Low-income and middle-income countries have a lot of problems in providing the financial, human, and capital resources for advanced medical imaging technologies (AMITs). Proper distribution of such expensive equipment might increase access to these services and enhance the quality and efficiency of health care. The present study aimed to identify the factors affecting the diffusion of AMITs including CT and MRI in Iran. This is a qualitative research conducted in 2017. A number of purposively chosen policy makers and managers from Ministry of Health, medical universities, hospitals, health insurance, and vendor companies were approached for face-to-face and semistructured interviews. Data analysis was done using thematic analysis method. Three categories of influential factors were identified, including contextual, stakeholder related, and situational factors. With regards to the stakeholders, the ministry and physicians played the most important role in the diffusion process of the AMITs. Health insurance organizations and vendor companies played a minor role in distribution of the equipment. Application of political pressure by the authorities on the Ministry of Health to issue licenses for the acquisition of AMITs was taken as the most important factor and the greatest challenge in the diffusion of devices. The results sought to assist health system authorities to manage diffusion of AMITs effectively and assign an equitable access to the expensive resources. The diffusion management together with utilization management could largely improve efficiency and cost containment. Medical technology diffusion management de facto needs policy instruments in both supply and demand sides.

Disruptive innovation and EU health policy

The two main policy issues are incentives for disruptive innovation and adoption and diffusion of such innovations. The first policy issue involve what economists call incentives for dynamic efficiency. How do we create incentives for development of valuable new technologies? Are the current incentives in favour of incremental or radical innovation (halfway technology) rather than disruptive innovation? Should more research be put into basic understanding of the disease, rather than the development of expensive hafway technologies? What is the role of health policy for the direction of innovation? Do reimbursement systems favour half way technologies? What about other health policies? Similar policy questions could be asked about adaptation and diffusion of technologies. One example is issues related to personalized medicine; do we need large scale public investment in testing, or should this be left to the market for individual decisions. The literature on diffusion of medical technologies offers a theoretical framework for further discussions. The classic reference is Rogers and many studies have been published using his model, and it may be a start to understand the specific issues related to diffusion of disruptive innovation [8]. Don Berwick is usually an interesting observer of the medical market place, and his review from 2003 may provide further insight [9]. Christensen notes how “strong institutional forces fight simpler alternatives to expensive care, because those alternatives threatens their livelihood.” He claims that this (monopolistic?) behaviour is not in the interest of the industry, and advocate opening up the market to competition. However, it is not obvious how competition should be introduced to support development of health care systems towards the dual goals of efficiency, both static and dynamic, and equity in health and health care delivery [10]. Christensen singles out four specific solutions to the present crises for the US health care system; (1) create—and then embrace—a system where the physicians skill level is matched to the level of the medical problem, (2) invest less money in high-end complex technologies, and more in technologies that simplify complex problems, (3) create new organizations to do the disrupting and (4) overcome the inertia of regulation. All four types of solutions may be relevant from a European perspective as well. Even if many European countries have developed further than the US on point one, support of self care and primary care and substitution of tasks between doctors and nurses, there are a number of issues related to innovation for the optimal use and training of health care professionals, not only physicians. The second point does not specify who is investing the money, but also in Europe it is mainly the private sector that invests in development of new technologies, and the public sector supports basic research. Private–public initiatives like IMI are under way, but creating the right incentives for investments in the desired type of technologies is a complicated process, where countries and firms collaborate and compete at the same time. It is well known that it is difficult to do new things in old institutions. But creating new institutions, and dismantling old institutions, is a tedious process and not accomplished over night. It is noticeable that the purchaser–provider split instituted in many health care systems, has taken decades of learning by doing (also mistakes) to create and develop. Changing regulation seems the easiest, but the legislative process needed to change regulations takes time, and can easily be delayed by interest opposed to the changes.

The Effect of Physician and Hospital Market Structure on Medical Technology Diffusion.

To examine the influence of physician and hospital market structures on medical technology diffusion, studying the diffusion of drug-eluting stents (DESs), which became available in April 2003. Medicare claims linked to physician demographic data from the American Medical Association and to hospital characteristics from the American Hospital Association Survey. Retrospective claims data analyses. All fee-for-service Medicare beneficiaries who received a percutaneous coronary intervention (PCI) with a cardiac stent in 2003 or 2004. Each PCI record was joined to characteristics on the patient, the procedure, the cardiologist, and the hospital where the PCI was delivered. We accounted for the endogeneity of physician and hospital market structure using exogenous variation in the distances between patient, physician, and hospital locations. We estimated multivariate linear probability models that related the use of a DES in the PCI on market structure while controlling for patient, physician, and hospital characteristics. DESs diffused faster in markets where cardiology practices faced more competition. Conversely, we found no evidence that the structure of the hospital market mattered. Competitive pressure to maintain or expand PCI volume shares compelled cardiologists to adopt DESs more quickly.

The effects of reimbursement mechanisms on medical technology diffusion in the hospital sector in the Italian NHS

ObjectivesThe aim of this study was to investigate how the differences across the regional reimbursement mechanisms and in particular the use of the DRGs impact on the level in the high technology equipment diffusion. MethodsBased on hospital sector data at a regional level we build up indicators to measure the regional diffusion of high technological medical equipment in the period 1997–2007. These indicators are regressed on regional healthcare characteristics to investigate the relationship between the different reimbursement systems offered by Italian regions and the level of high technological medical equipment. ResultsOur results suggest that the per-case payment system is generally associated with a lower level of regional technology endowment per million of inhabitants, especially for the complex and expensive medical equipments. ConclusionsOur findings cast some doubts that an effective regulation of reimbursement mechanisms cannot limit the excessive diffusion of medical equipment that is a relevant driver of the increase in expenditure.

The Impact of Star Physicians on Diffusion of a Medical Technology: The Case of Laparoscopic Gastric Bypass Surgery

Using data on all bariatric surgeries performed in the state of Pennsylvania from 1995 through 2007, this paper uses logistic and OLS regressions to measure the effect of star physicians and star hospitals on the diffusion of an innovation in bariatric surgery called laparoscopic gastric bypass surgery (LGBS). This paper tests for effects at both the hospital and physician level. Compared to hospitals with no star physicians (11% adoption rate), those with star physicians on staff show a much higher adoption rate (89%). Compared to hospitals which are not classified as star hospitals (13% diffusion rate), hospitals with star status show a much higher diffusion rate (87% ) from first quarter 2000 to fourth quarter 2001. At the physician level, the empirical results indicate that star physicians exert positive asymmetric influence on the adoption and utilization rates of non-stars at the same hospital. Star physicians are those who: (i) graduated from a Top 30 medical school or (ii) completed residency at a Top 30 hospital or (iii) are included in a Castle & Connolly Top Doctors ® publication. Star hospitals are those with Council of Teaching Hospital (COTH) certification. The results of this paper support earlier work on the role of key individuals in technology diffusion. It extends research on medical technology diffusion by testing a new data set for a chronic disease treatment.

Diffusion of medical technology: The role of financing

In the last decade the pace of innovation in medical technology has accelerated: hence the need to better identify and understand the real forces behind the adoption and diffusion of medical technology innovations in clinical practice. Among these forces, financial incentives may be expected to play a major role. The purpose of this paper was to assess the influence of financing mechanisms for new medical devices and correlated procedures on their diffusion. The analysis was carried out in the Italian inpatient cardiovascular area and applied to drug eluting stents over the period 2003-07. The paper's main hypothesis, that higher levels of reimbursement encourage technology diffusion, was rejected. So was the hypothesis that private hospitals may be more sensitive to tariff levels than public hospitals. A statistically significant difference was found only between hospitals that are funded on a Diagnosis-Related Groups (DRGs) basis and those that are not, with the former showing higher levels of technology diffusion. These results warn policy makers against excessive reliance on specific reimbursement fee changes as a way of steering provider behaviour.

Changes in the use of hematopoietic stem cell transplantation: a model for diffusion of medical technology

Innovations in hematology spread rapidly. Factors affecting the speed of introduction, international diffusion, and durability of use of innovations are, however, poorly understood. We used data on 251,106 hematopoietic stem cell transplants from 591 teams in 36 European countries to analyze the increase and decrease in such transplants for breast cancer and chronic myeloid leukemia and the replacement of bone marrow by peripheral blood as the source of stem cells as processes of diffusion. Regression analyses were used to measure the quantitative impact of defined macro- and microeconomic factors, to look for significant associations (t-test), and to describe the coefficient of determination or explanatory content (R(2)). Gross national income per capita, World Bank category, team density, team distribution, team size, team experience and, team innovator status were all significantly associated with some or all of the changes. The analyses revealed different patterns of associations and a wide range of explanatory content. Macro- and micro-economic factors were sufficient to explain the increase of allogeneic hematopoietic stem cell transplants in general (R(2) = 78.41%) and for chronic myeloid leukemia in particular (R(2) = 79.39%). They were insufficient to explain the changes in stem cell source (R(2) =26.79% autologous hematopoietic stem cell transplants; R(2) = 9.67% allogeneic hematopoietic stem cell transplants) or the decreases in hematopoietic stem cell transplants (R(2) =10.22% breast cancer; R(2)=33.17% chronic myeloid leukemia). The diffusion of hematopoietic stem cell transplants is more complex than previously thought. Availability of resources, evidence, external regulations and, expectations were identified as key determinants. These data might serve as a model for diffusion of medical technology in general.

Design of a National Distributed Health Data Network

A distributed health data network is a system that allows secure remote analysis of separate data sets, each comprising a different medical organization's or health plan's records. Distributed health data networks are currently being planned that could cover millions of people, permitting studies of comparative clinical effectiveness, best practices, diffusion of medical technologies, and quality of care. These networks could also support assessment of medical product safety and other public health needs. Distributed network technologies allow data holders to control all uses of their data, which overcomes many practical obstacles related to confidentiality, regulation, and proprietary interests. Some of the challenges and potential methods of operation of a multipurpose, multi-institutional distributed health data network are described.

The National Oncologic PET Registry: Lessons Learned for Coverage With Evidence Development

The National Oncologic PET Registry (NOPR) was one of the first attempts of the Centers for Medicare & Medicaid Services (CMS) at coverage with evidence development. Under this coverage policy, the agency will provide payment for a technology only if patients and providers agree to enroll in a prospective study or registry. The NOPR was designed to determine if the results of positron emission tomography scans influence physicians' intended plans of patient management while imposing minimal restrictions on the use of such scans in the clinical setting. The experience of policymakers, methodologists, physicians, and patients with the NOPR provides some useful insights into the utility and challenges of implementing, financing, and creating a robust methodology for coverage with evidence development in the future. Moving to a system of evidence-based medical technology diffusion will require all health care decision makers to become involved in evidence generation and reach an agreement about the type of evidence required to make informed medical decisions.

Diffusion of medical technology: medical devices in India

This review examines the diffusion of modern medical devices in India by analyzing trends in India’s cross-border trade in medical devices, its domestic medical device production and utilization by households. We explore the implications of this process of diffusion for the efficacy, cost–effectiveness and equitable use of new medical devices in India, and review recent efforts to regulate the Indian medical device sector.

Diffusion Of New Technology And Payment Policies: Coronary Stents

Medicare payment is often cited as a major driver of medical technology diffusion. Stakeholders claimed that beneficiaries would be denied access to stents because Medicare payment did not initially cover the cost of stents. Nevertheless, stents diffused rapidly, including to untested indications. Outcomes with stents improved over time, primarily because of a fundamental property of technology diffusion termed "reinvention," in which new technology is modified by users. The traditional system of regulatory approval and reimbursement does not account for this dynamic process. There has been no incentive for systematic collection of data to determine which modifications are most beneficial.

Tort Reform, Defensive Medicine, and the Diffusion of Diagnostic Technologies

This study examines the effects of state-level, tort law reforms on the diffusion of medical technology in the United States. The central thesis focuses on the diffusion of medical technology as an indicator of defensive medicine. Specifically, if physicians reduce their level of defensive medicine in the wake of liability reforms, this will show up as a reduction in the demand for and, more importantly, in the quantity supplied of medical technology. I discover after analyzing panel-data reflecting the availability of hospital-based diagnostic technologies by states and for the years 1987, 1990, and 1993 that differences in the availability of the technology are partially the result of state-level liability reforms. Moreover, there are significant differences in the impact of reforms on established (diffused) technologies and newer (diffusing) technologies. The results provide further evidence of the existence of defensive medicine and of the impact of the legal environment on the diffusion of medical technology.

International Medical Technology Diffusion

Does medical technology originating in countries close to the technology frontier have a significant impact on health outcomes in countries distant from this frontier? This paper considers a framework where lagging countries may benefit from medical technology (a result of research and development by countries close to the frontier) that is embodied in medical imports or diffuses in the form of ideas. Using a novel dataset from a cross-section of 73 technology-importing countries, we show that medical technology diffusion is an important contributor to improved health status, as measured by life expectancy and mortality rates.