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PubMed1993

Minimally invasive surgery. Implications for hospitals, health workers, and patients.

Minimally invasive surgery is one of the great innovations of health care in the 20th century. It promises to revolutionise surgery by allowing many more operations to be performed with minimal hospitalisation. Pressure from patients has caused many techniques to spread rapidly before they have been adequately assessed. This must be resisted, and policy makers must pay more attention to minimally invasive surgery to ensure that good assessments are made. The widespread use of minimally invasive techniques has important implications for hospitals and health workers. As more patients are treated on an outpatient basis, fewer hospital beds will be needed, and traditional operating rooms will have to adapt to a greater turnover of patients. Surgeons will have to acquire new operating skills, possibly requiring formal training and accreditation, and, as different specialties fight for control of new technologies, surgery may eventually be merged with internal medicine so that specialists will deal with organ systems. Postoperative care will have to be carried out in the community rather than in hospitals, and policy makers will need to reorganise their health systems to cope with these developments.

Clinical Competence↗

PubMed2001

Assessment of new cardiovascular drugs. Relationships between considerations, professional characteristics, and prescribing.

OBJECTIVES: To study considerations used by professional and academic leaders to assess the position of new cardiovascular drugs in the therapeutic regimen in relationship to professional characteristics and the level of prescribing. METHODS: Interviews with 39 internists, cardiologists, general practitioners, and hospital pharmacists about considerations regarding the therapeutic position and prescribing of a new cardiovascular drug (losartan or atorvastatin) and professional characteristics. Considerations were classified according to Rogers' characteristics of an innovation, i.e., referring to the drug's relative advantage, compatibility, or complexity. Proportions of respondents mentioning advantageous, comparable, and/or disadvantageous characteristics were used to construct patterns to analyze an overall evaluation of the drugs in relation to professional characteristics and level of prescribing. RESULTS: The majority of considerations referred to the degree of relative advantage, but different subjects were emphasized for both drugs. Overall patterns of evaluation were generally intermediate and negative. The respondents' profession, mentioning commercial sources of information and self-qualification as a (moderately) early adopter of new drugs differentiated the overall evaluation of the drugs, in contrast to expertness and academic affiliation. The level of prescribing differentiated the overall evaluation only in the case of losartan. CONCLUSIONS: These professional and academic leaders critically evaluated the claims when assessing the position of the drugs in the therapeutic regimen but did not show consensus in their considerations. Accepted principles for prescribing were considered when assessing the therapeutic position of the drugs but resulted in varied tendencies for prescribing.

Cardiovascular Agents↗

PubMed2006

The experience of Australian project leaders in encouraging practitioners to adopt research evidence in their clinical practice.

OBJECTIVE: This paper describes a qualitative program evaluation which sought to identify factors that either assist or impede the adoption of clinical evidence in everyday practice. DESIGN AND PARTICIPANTS: Thirteen Australian projects were funded in a competitive grant program to adopt innovative strategies to improve the uptake of research evidence in everyday clinical practice. Project leaders' reports were analysed to collate common themes related to 1) critical elements in successful application of research knowledge, 2) barriers to implementing evidence, and 3) lessons for other organisations that might implement a similar project. RESULTS: Despite the diversity of the methods used to establish projects and the range of topics and clinical settings, many similarities were identified in the perceived critical success elements, barriers, and lessons for adopting clinical evidence. Eighteen themes emerged across the data including: leadership support; key stakeholder involvement; practice changes; communication; resources; education of staff; evaluation of outcomes; consumers; knowledge gaps; adoption/implementing staff; access to knowledge; risk assessment; collaboration; effectiveness of clinical research evidence; structure/organisation; cultural barriers; previous experiences; and information technology. CONCLUSION: Leaders of projects to adopt evidence in clinical practice identified barriers, critical success elements and lessons that impacted on their projects. A range of influences on the adoption of evidence were identified, and this knowledge can be used to assist others undertaking similar projects.

Australia↗

PubMed2001

Factors of the innovation, organization, environment, and individual that predict the influence five systematic reviews had on public health decisions.

OBJECTIVE: To determine the extent to which systematic reviews of public health interventions influenced public health decisions and which factors were associated with influencing these decisions. METHODS: This cross-sectional follow-up survey evaluated the use of five systematic reviews in public health decision making. Independent variables included characteristics of the innovation, organization, environment, and individual. Primary data were collected using a telephone survey and a self-administered organizational demographics questionnaire. Public health decision makers in all 41 public health units in Ontario were invited to participate in the study. Multiple linear regression analyses on the five program decisions were conducted. RESULTS: The systematic reviews were perceived as having the greatest amount of influence on decisions related to program justification and program planning, and the least influence on program evaluation decisions. The greater the perception that one's organization valued the use of research evidence for decision making and that ongoing training in the critical appraisal of research literature was provided, the greater the perception of the influence the systematic review had on public health decisions. CONCLUSIONS: Organizational characteristics are important predictors of the use of systematic reviews in public health decision making. Future dissemination strategies need to promote the value of using systematic reviews for program decision making as well as promote ongoing training in critical appraisal among intended users in Ontario.

Cross-Sectional Studies↗

PubMed1998

Local implementation of national guidelines on lower urinary tract symptoms: what do general practitioners in Sydney, Australia suggest will work?

OBJECTIVES: Systematic reviews demonstrate that local initiatives are vital to implement nationally developed clinical practice guidelines. Evidence-based guidelines on the management of lower urinary tract symptoms in men were launched by the National Health and Medical Research Council in Sydney in April 1997. A study was conducted through interviews to establish patterns of care in the catchment area before the guidelines were implemented and general practitioners were surveyed in order to ascertain the most useful strategies for local implementation. DESIGN: A four-page questionnaire asked respondents to rate nine items about guideline dissemination; six items relating to the marketing of the guidelines and 15 implementation strategics: conventional educational activities (six); innovative educational strategies (four); quality improvement approaches (two) and patient-based approaches (three). SETTING: Sydney, Australia. STUDY PARTICIPANTS: Eighty-three randomly selected general practitioners (50 males; 33 females). RESULTS: Eighty-three out of 108 surveys were returned (77%). Respondents placed high value upon endorsement by eminent individuals and organizations other than the organization developing the guidelines; this was likely to gain their initial attention. One hundred per cent of respondents would be encouraged to use the guidelines if they were promoted as improving quality of care. Implementation strategies preferred by respondents included small group continuing education with a urologist and a general practitioner as a facilitator, lectures and patient education materials. Internet access, interactive computer systems, academic detailing' and distance education modules were of least interest. CONCLUSIONS: Our method is feasible as a first step in planning local dissemination and implementation for national guidelines. While useful in identifying preferred strategies, its longer-term predictive validity for improving patient outcomes through better guideline implementation needs to be established.

Adult↗

PubMed1991

Assessing the congruence between physician behavior and expert opinion in smoking cessation counseling.

This study examines the degree of transfer of smoking cessation innovation from research to health care settings by comparing frequency-of-practice ratings by a national sample of family practice physicians (n = 903, response rate = 70%) and importance ratings by smoking cessation and prevention experts (n = 58, response rate = 84%) for 14 counseling techniques. The physician survey elicited a profile that combines traditional and behavioral techniques--discussing smoking with patients, encouraging goal setting, suggesting specific steps for quitting, and presenting pamphlets. They refer to others infrequently and rarely report planning for follow-up about smoking. The experts rated these selected techniques as moderately to highly important. They favored a behavioral approach coupled with active follow-up. The major differences between physician and expert rankings were that the experts placed higher priority on planned follow-up and a lower priority on pamphlets. The uneven quality of counseling reported by physicians suggests that weighting their responses according to expert opinion would provide a more sensitive profile. Scaled weighting produced scores that may help researchers define a composite quality-quantity measure of activity.

Adult↗

PubMed2005

Information communications technology in general practice: cross-sectional survey in London.

OBJECTIVE: To determine the prevalence of use of a range of information and communications technology (ICT) applications in general practice in London, UK. DESIGN: Cross-sectional postal questionnaire study. PARTICIPANTS: 996 general practitioners (GPs) working in 32 primary care trusts (PCTs) in London. MAIN OUTCOME MEASURES: Rates of self-reported use of paperless, paper-light and paper-based consultations in general practice, perceived barriers and facilitating factors relating to their use and current use or interest in using innovative ICT. RESULTS: Questionnaires from 520 respondents (52%) were analysed. A computer was used in clinical consultations by 95% of respondents; 34% operated paper-light consultations, and 41% paperless consultations. An electronic record was always used in 76% of consultations and paper records were never used in 19%. Paper-light and paperless consultations were conducted more frequently in larger practices and those in more affluent PCTs. Numerous barriers to the implementation of ICT were identified, including lack of time, lack of training resources and negative attitudes to computers. Personal digital assistants were used by 18% of respondents and 72% were interested in their use in the future. CONCLUSION: We have shown that there has been a considerable increase in the rate of use of ICT in general practice in recent years, but these rates have fallen behind targets set by the NHS IT Strategy. Numerous barriers to the implementation of ICT exist, and further research is needed into means of overcoming them and on the evaluation of computer-supported consultations and other technologies in primary care.

Attitude to Computers↗

PubMed2006

How are decisions to introduce new surgical technologies made? Advanced laparoscopic surgery at a Canadian community hospital: A qualitative case study and evaluation.

The introduction of many new surgical technologies is associated with increased costs and uncertainty regarding risks and benefits. Currently, little is known about how decisions are made regarding the adoption of surgical innovations. To study the decision-making process for adoption of advanced laparoscopic surgical procedures at a community hospital in Toronto, Canada, we used qualitative case study methods. Data were collected using semi-structured interviews with key informants. We performed a modified thematic analysis of the data, using the conceptual framework for priority setting known as accountability for reasonableness, which consists of 4 conditions: relevance, publicity, appeals, and enforcement. Several advanced laparoscopic surgical procedures were introduced at the hospital between 2000 and 2005. During that time, there was no structured, explicit process for making decisions about introducing new surgical technologies. Use of the new surgical technologies was relevant, as measured by the perception of patient benefit and alignment with the hospital's strategic priorities. There was no systematic structure in place to oversee publicity, appeals, or enforcement. The decision to adopt advanced laparoscopic surgery at a community hospital in Toronto, Canada, was made primarily on the basis of its relevance to patient care. The process for making decisions about the adoption of new surgical technologies can be improved.

Decision Making, Organizational↗

PubMed2003

Exploring the dimensionality of the Originality subscale of the Kirton Adaption-Innovation Inventory.

The Kirton Adaption-Innovation Inventory, which is a widely used measure of innovative (as opposed to adaptive) cognitive individual style, is believed to have three dimensions: Sufficiency of Originality, Efficiency, and Rule/Group Conformity. Several studies have raised concerns regarding its construct validity, specifically with respect to the Sufficiency of Originality subscale. Within this subscale, exploratory factor analysis identified two distinct subdimensions, Idea Generation and Preference for Change. In this study, we used a sample of 356 household participants (with an average age of 56 yr., average income of 39,700 dollars, and average of 15 yr. of education) from the Arkansas Household Research Panel. We then employed Bollen and Grandjean's approach based on confirmatory factor analysis to assess whether there are actually two distinct subdimensions instead of one. Our study shows that within the Sufficiency of Originality subscale, there are indeed two distinct subdimensions, Idea Generation and Preference for Change. Further analyses indicate that dropping double-loaded items identified through exploratory factor analysis significantly improves the fit statistics. Also, allowing correlated errors for the measurement items that belong to the same subdimension can also significantly improve the overall fit of the model based on chi-square statistics.

Adaptation, Psychological↗

PubMed2004

Critical analysis of trends in fusion for degenerative disc disease over the past 20 years: influence of technique on fusion rate and clinical outcome.

STUDY DESIGN: Critical analysis of the results reported in published literature. OBJECTIVES: The purpose of this study was to evaluate whether various technical advancements have affected the outcome of lumbar spinal fusion for degenerative disease by critically analyzing the available literature from the past two decades. SUMMARY OF BACKGROUND DATA: To improve fusion rate and clinical outcome, various surgical options for lumbar spinal fusion for degenerative disc disorders have been introduced over the past 20 years. However, an important fundamental question still remains: What has been the impact of these new techniques and innovations on surgical results? METHODS: A comprehensive computer search of the English literature from 1979 to 2000 concerning lumbar/lumbosacral spinal fusion was performed using the keywords degenerative, lumbar, and fusion. RESULTS: Numerous deficiencies were noted in the reviewed literature. Nearly half of the studies failed to specify methodologic design, and documentation of brace use, graft source, fusion location, and fusion rate was missing in 38, 10, 2, and 4 of the 84 articles reviewed, respectively. From the data gathered, a noticeable trend toward the increasing use of internal fixation was noted, accounting for 23% of fusions in the 1980s versus 41% in the 1990s. Despite this trend, an improvement in overall fusion rate or clinical outcome could not be demonstrated. CONCLUSIONS: Numerous technologic advancements in lumbar spine fusion have been made over the past 20 years. Future advances in care are dependent on review of reported results. The numerous deficiencies detected in the analyzed literature herald the necessity for a uniform system of outcomes reporting containing a core of critical demographic, perioperative, and postsurgical information. Although a shift toward a greater use of technology was noted in the published literature, the clinical benefit of this trend remains unclear.

Diffusion of Innovation↗

PubMed2003

An ESID case study at the federal level.

The D (dissemination) phase of the ESID model has been often overlooked in our efforts to create innovative and widespread social change. The process of replicating successful social innovations is both a prerequisite for dissemination (in order to assess the consistency of effects) and an obvious outcome of a successful dissemination effort. Fidelity, the extent to which a replicated program is implemented in a manner consistent with the original program model, is an important dimension of replication. This study was designed to provide empirical data related to three questions. Can complex social programs be implemented with fidelity? How much fidelity is appropriate or desired? What are the organizational dynamics of adoption with fidelity? Data were collected from grantees of a national replication initiative funded by the Center for Substance Abuse Prevention. Data suggest that high fidelity can be achieved, at least in the context in which programs are mandated to do so as part of the funding agreement and are given technical assistance in achieving fidelity. Secondly, programs perceived high fidelity as having positive effects on the program and its participants, a finding consistent with a limited assessment of the relationship of program outcomes and fidelity. Finally, much was learned about the human and organizational dynamics of replicating with fidelity. Implications for policy and direction regarding replication are discussed.

Diffusion of Innovation↗

PubMedDate not supplied

Patient-provider connectivity and the role of e-health.

Patient-provider connectivity (PPC) offers innovative approaches to control costs, improve quality, and sustain a healthy workforce. The application of e-commerce to health care is one facet of PPC and provides solutions to educating, informing, and more efficiently using scarce resources to sustain the nation's health. Technology is available to provide real-time access to clinical results, medical records, health-care providers, and other time-sensitive patient information. This is the first article in a series on PPC that explores the application of e-commerce to the health-care industry from the consumers' and providers' points of view and examines and assesses trends and data from various interdisciplinary sources and studies. Two models exemplifying PPC are explored including the Science Business & Education, Inc., proof-of-concept patient demonstration project, and the emerging application of peer-to-peer (P2P) technology. PPC promises to improve efficiency, facilitate communication between physician and patient, monitor compliance with medical regimens, and positively affect the quality of health care provided and the overall health of the patient. Future articles will address the growth of telemedicine, issues of confidentiality and e-risk, and other PPC applications.

Clinical Laboratory Information Systems↗

PubMed2005

Reducing waste and errors: piloting lean principles at Intermountain Healthcare.

BACKGROUND: The Toyota Production System (TPS), based on industrial engineering principles and operational innovations, is used to achieve waste reduction and efficiency while increasing product quality. Several key tools and principles, adapted to health care, have proved effective in improving hospital operations. TOOLS: Value Stream Maps (VSMs), which represent the key people, material, and information flows required to deliver a product or service, distinguish between value-adding and non-value-adding steps. The one-page Problem-Solving A3 Report guides staff through a rigorous and systematic problem-solving process. PILOT PROJECT at INTERMOUNTAIN HEALTHCARE: In a pilot project, participants made many improvements, ranging from simple changes implemented immediately (for example, heart monitor paper not available when a patient presented with a dysrythmia) to larger projects involving patient or information flow issues across multiple departments. Most of the improvements required little or no investment and reduced significant amounts of wasted time for front-line workers. In one unit, turnaround time for pathologist reports from an anatomical pathology lab was reduced from five to two days. CONCLUSIONS: TPS principles and tools are applicable to an endless variety of processes and work settings in health care and can be used to address critical challenges such as medical errors, escalating costs, and staffing shortages.

Cost Control↗

PubMedDate not supplied

The adoption of complementary and alternative medicine by hospitals: a framework for decision making.

As a result of increased consumer awareness, personal preference, and limitations of conventional medicine, many individuals are turning to complementary and alternative medicine (CAM). In response to this movement, many community hospitals are striving to be innovative providers. Society is leaning toward a more comprehensive style of healing that incorporates all aspects of wellness. During the last three decades, the public has increasingly used CAM. Arnold (1999) cited a study published in the Journal of the American Medical Association that reported that 39 million people sought either advice or treatment from a CAM provider and 42 percent of Americans used some form of alternative therapy. With the population becoming increasingly educated, aware, and proactive about wellness, many Americans see CAM as an effective alternative to traditional medicine. Healthcare organizations have responded, although slowly, to this trend, as new alternative medicine clinics, hospital departments, and research centers emerge throughout the United States. Although alternative medical practices are being used by an increasing number of people, there is still limited understanding of what CAM includes and how it influences health services organizations. Understanding this new market and its implementation in the healthcare setting is of interest to healthcare administrators. This article defines CAM, discusses its rising popularity, identifies its adoption in today's hospitals, and depicts barriers to its implementation. Finally, an analytical framework developed by the author is used to suggest factors for administrators to consider in CAM implementation in their organizations.

Complementary Therapies↗

PubMed2005

Women as moral pioneers? Experiences of first trimester antenatal screening.

The implementation of innovative medical technologies can raise unprecedented ethical, legal and social dilemmas. This is particularly so in the area of antenatal screening, which is dominated by the language of risk and probabilities. Second trimester serum screening for Down's syndrome and neural tube defects has a well-established place in antenatal care. Increasingly, first trimester screening with biochemical and ultrasound markers is being proposed as advance on this, yielding higher detection rates of Down's syndrome at an earlier gestational age. This article explores the experiences of 14 women offered innovative first trimester screening, which takes place within the context of a detailed ultrasound scan. The study is set within the UK, where recent policy changes mean that the offer of screening for fetal anomalies, particularly Down's syndrome, will become a routine part of antenatal care and offered to all pregnant women. This paper focuses on the significance of the scan in first trimester screening, and some of the potential dilemmas for women that can result from this. It then discusses the ways in which women made their decisions about screening, in particular, their work as 'moral pioneers'. We found that the part played by the ultrasound scan in first trimester screening, particularly in relation to the higher-quality images now being obtained, has the potential to introduce new and novel ethical dilemmas for pregnant women. Although concerns have been raised about pregnant women viewing ultrasound scans as benign, many of the women reported having thought carefully through their own moral beliefs and values prior to screening. It seems that whatever other implications they may have, first trimester screening technologies will continue the tradition of pregnant women acting as 'moral pioneers' in increasingly complex settings.

Adult↗

PubMed2006

Transformational and transactional leadership: association with attitudes toward evidence-based practice.

OBJECTIVE: Leadership in organizations is important in shaping workers' perceptions, responses to organizational change, and acceptance of innovations, such as evidence-based practices. Transformational leadership inspires and motivates followers, whereas transactional leadership is based more on reinforcement and exchanges. Studies have shown that in youth and family service organizations, mental health providers' attitudes toward adopting an evidence-based practice are associated with organizational context and individual provider differences. The purpose of this study was to expand these findings by examining the association between leadership and mental health providers' attitudes toward adopting evidence-based practice. METHODS: Participants were 303 public-sector mental health service clinicians and case managers from 49 programs who were providing mental health services to children, adolescents, and their families. Data were gathered on providers' characteristics, attitudes toward evidence-based practices, and perceptions of their supervisors' leadership behaviors. Zero-order correlations and multilevel regression analyses were conducted that controlled for effects of service providers' characteristics. RESULTS: Both transformational and transactional leadership were positively associated with providers' having more positive attitudes toward adoption of evidence-based practice, and transformational leadership was negatively associated with providers' perception of difference between the providers' current practice and evidence-based practice. CONCLUSIONS: Mental health service organizations may benefit from improving transformational and transactional supervisory leadership skills in preparation for implementing evidence-based practices.

Adult↗

PubMed1998

[Community nutrition strategy project: an innovation in community health].

The strategy of the community nutrition project is based on the utilization of the community development structures to deliver the nutrition services. These structures, represented in Senegal by youth associations, women groups, GIEs and NGOs, are part of the decentralization process, and as such play an important role in health and health development activities in poor urban districts. The Community Nutrition Project (CNP), funded for five years by the World Bank, German Cooperation (KFW), World Food Program (WFP) and the Senegalese government aims to halt further deterioration in the nutrition status of the most vulnerable groups in the poorest urban districts of Senegal. All nutrition services and particularly the IEC services have been entirely contracted out the first year to 76 GIEs involving 323 unemployed persons, operating as micro-enterprises "MIC" and 17 "GIEs" of unemployed physicians, pharmacists, and social workers for a total of 34 persons, organized as "maître d'Oeuvre communautaires "MOC", in charge of the supervision tasks. Each community nutrition center recruits and monitors every six months 460 to 600 beneficiaries composed of women at six months of pregnancy, lactating mother of children under 6 months, and a group of children aged from 6 to 35 months old. An average of 87% of registered children in the nutrition centers are weekly or monthly weighted. Thus the proportion of malnourished children in cohort of children followed from January to July 1996 has decreased from 70% to 25% within six months. The malnutrition rate has been reduced up to 65% after six months.

Adult↗

PubMed2001

The impact of assessing the prevalence of pressure ulcers on the willingness of health care institutions to plan and implement activities to reduce the prevalence.

BACKGROUND: In 1998, 89 health care institutions (hospitals, nursing homes, residential homes, and community care institutions) participated in the first Dutch National Pressure Ulcer Prevalence Study. AIM: Based on the innovation-decision process for individuals (Rogers 1995), the effect of their participation was investigated at different levels in the institutions [prevalence assessment coordinator, director, ward management (enrolled) nurses, and the pressure ulcer committee]. METHOD: A mail questionnaire was developed and filled out by 54 coordinators of the participating health care institutions. RESULTS: Results showed that according to the coordinators most levels of the institutions were familiar with the results of the prevalence assessment, understood them, and were persuaded that their prevalence rate had to be changed. As a result, almost all of the coordinators of the institutions were planning activities to change pressure ulcer management, while half of the coordinators had already implemented some actions. The main activities planned or implemented were developing or updating the prevention and treatment protocol and educating the (enrolled) nurses. Some institutions were planning or had already implemented the appointment of a nurse specialist or a nurse paying special attention to pressure ulcers. Results showed that the different levels of the institutions took initiatives on different categories of activities. CONCLUSION: It is concluded that participating in the first national prevalence study was a positive experience for the institutions, because agenda-setting took place and most started to plan or implement activities to improve the prevention and treatment of pressure ulcers.

Cross-Sectional Studies↗