The determinants of medical technology adoption in different decisional systems: A systematic literature review.

Studies of determinants of adoption of new medical technology have failed to coalesce into coherent knowledge. A flaw obscuring strong patterns may be a common habit of treating a wide range of health care innovations as a generic technology. We postulate three decisional systems that apply to different medical technologies with distinctive expertise, interest, and authority: medical-individualistic, fiscal-managerial, and strategic-institutional decisional systems. This review aims to examine the determinants of the adoption of medical technologies based on the corresponding decision-making system. We included quantitative and qualitative studies that analyzed factors facilitating or inhibiting the adoption of medical technologies. In total, 65 studies published between 1974 and 2014 met our inclusion criteria. These studies contained 688 occurrences of variables that were used to examine the adoption decisions, and we subsequently condensed these variables to 62 determinants in four main categories: organizational, individual, environmental, and innovation-related. The determinants and their empirical association with adoption were grouped and analyzed by the three decision-making systems. Although we did not identify substantial differences across the decision-making systems in terms of the direction of the determinants' influence on adoption, a clear pattern emerged in terms of the categories of determinants that were targeted in different decision-making systems.

Implementing evidence-based practice: evaluation of an opinion leader strategy to improve breast-feeding rates.

OBJECTIVE: The objective was to evaluate the effectiveness of opinion leaders in raising breast-feeding rates. STUDY DESIGN: A randomized controlled trial of an opinion leader strategy in 18 hospitals in Central New York State compared mothers' intention to breast-feed during baseline and study years. Multivariate logistic regression with a mixed model analyzed the effects on breast-feeding exclusively and on breast- and formula-feeding combined. RESULTS: Obstetric clinicians had a high degree of knowledge about breast-feeding benefits and of perceived responsibility to recommend breast-feeding. Obstetricians, family practitioners, and midwives agreed on the person identified as the opinion leader, in each case an obstetrician who was chief of obstetrics or obstetrics-gynecology. Breast-feeding rates in hospitals with the opinion leader intervention did not differ significantly from those in control-group hospitals during the study year. CONCLUSION: The opinion leader strategy in this case did not improve breast-feeding rates during the study year. Opinion leader strategies may make assumptions about clinician control that are not justified in situations such as breast-feeding.

Bringing the patient back in. Guidelines, practice variations, and the social context of medical practice.

We challenge assumptions that have guided much research and policy aimed at understanding and reducing medical practice variation. Paramount is the focus on doctors as the cause of variation to the neglect of other possible influences. Some research literature suggests that patients, families, and the community context of practice may also influence treatment decisions. Failure to question present assumptions, despite weak evidence in support of them, may account for inability to explain persistent practice variation, develop appropriate implementable guidelines, or anticipate the effect on treatment decisions of greater patient involvement. In this paper, we discuss the weak response to the NIH Consensus Conference on early stage breast cancer because it may have reflected these problems. We urge a more complex and more empirical approach in explaining treatment choice and guidelines sensitive to the potential for value differences.