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5
Physicians' Decisions Regarding the
Acquisition of Technology
A. MARK FENDRICK AND J. SANFORD SCHWARTZ
The quality and cost of medical care have recently come under intense scru-
tiny. Identification of the forces that drive the health care system may help
policymakers determine ways to allocate those scarce resources devoted to health
care more equitably and efficiently. Although payments to physicians account
for less than 20 percent of total health care expenditures, physicians generate
nearly 80 percent of the total services delivered (Eisenberg, 19861. Further un-
derstanding of the physician's decisionmaking process for the adoption of medi-
cal innovations may aid in the enormous task of bringing significant health care
reform to the United States.
INCENTIVES FOR THE ADOPTION
OF MEDICAL INNOVATIONS
Medical tradition emphasizes giving the best care that is technically possible;
the only legitimate and explicitly recognized constraint is the state of the art
(Fuchs, 1968~.
Substantial evidence indicates that physicians are receptive to technological
advances. The "technological imperative," or the desire to do anything and ev-
erything possible for a patient, is considered to be a major influence on the
adoption of medical innovation (Altman and Blendon, 1979; Kressley, 19811.
The pharmaceutical and medical device industries annually supply thousands of
new products that offer the potential for improved diagnostic capabilities and
new, more sophisticated treatments. Approximately one in three practitioners
adopts a new technology in a given year (Freiman, 19851. Although the adoption
71
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72
A. MARK FENDRICK AND J. SANFORD SCHWARTZ
and use of each of these innovative technologies is guided by the expectation of
improved clinical outcomes, these decisions are frequently based on less-than-
sufficient data.
Ideally, decisions regarding the adoption of a medical innovation by physi-
cians would be based on results drawn from research performed from a number
of different perspectives, addressing endpoints important to patients, providers,
payers, and society. In theory, this information would be derived from rigorously
designed and conducted controlled experiments that produce unambiguous re-
sults. The findings from these investigations would allow physicians to make
better-informed and more rational choices, leading to the rapid adoption of rela-
tively beneficial innovations, inhibition of the adoption of interventions that are
judged to provide fewer benefits relative to their costs, and prevention of the
diffusion of those technologies that are not beneficial (or that are even harmful).
Although the adoption of quality-enhancing, cost-saving, or cost-effective
medical innovations is desirable, the early and more widespread adoption of
expensive innovations with unknown benefits is not. There is much room for
improvement in the ways that we assess the net benefits of medical care interven-
tions (Fineberg and Hiatt, 1979~. In addition, there is general agreement that the
reimbursement process for medical innovation, which currently requires little in
the way of information on clinical and economic outcomes, must be modified to
slow the adoption of unproved interventions and to facilitate or even encourage
more rigorous evaluation efforts. The implementation of a nonprofit reimburse-
ment system during the evaluative stages of a novel technology would dampen
the usual market forces that may encourage the early dissemination of innova-
tions not yet determined effective (James, 1991) while also minimizing economic
disincentives that may prevent further technological advances.
Unfortunately, reality diverges from theory in that financial incentives in the
form of generous reimbursement of providers for new procedures and diagnostic
tests have been identified as a particularly important stimulus to the adoption of
medical innovations (Hemenway et al., 1990; Hichson et al., 1987; lIillman et
al., 1989; McGivney, 1988~. Furthermore, there may be a disincentive for pro-
viders to adopt an innovation when reimbursement levels are deemed less than
adequate for its use (e.g., cochlear implants). In addition, valid and reliable
outcomes data on the safety, efficacy, and cost-effectiveness of many medical
interventions do not exist prior to widespread adoption (Chalmers, 19741. Limi-
tations on time, expense, and practicality are primarily responsible for the ab-
sence of controlled experiments in many clinical areas. In today's competitive
health care environment, decisions regarding the adoption and reimbursement of
medical technology must be made quickly and, often, those who make the deci-
sions must rely on imperfect or nonexistent effectiveness data generated by eval-
uative methodologies of suboptimal rigor. The end result is an inconsistent pat-
tern of adoption and diffusion that has led to the underutilization of some
effective technologies (e.g., immunizations), the widespread utilization of some
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PHYSICIANS' DECISIONS REGARDING ACQ UISITI ON OF TECHNOLOGY 73
technologies of unproven efficacy (e.g., fetal monitoring), and the use of some
later found to be ineffective and even harmful (e.g., gastric bubble).
CONCEPTUAL MODEL
Conceptual models can facilitate understanding of why and how physicians
adopt a medical innovation. The model shown in Figure 5-1 is adapted from
earlier research in the field of diffusion of innovation (Greer, 1977, 1988;
Kaluzny, 1974; Rogers and Shoemaker, 1971; Warner, 1974~. The use of sche-
matics such as this can help provide an understanding of physician decisionmak-
ing behavior. However, the evidence available to date indicates that it is difficult
to change physician behavior on a significant level (Eisenberg, 1986; Eisenberg
and Williams, 1981; Kanouse and Jacoby, 1988~.
Innovation Characteristics
Factors inherent to an innovation itself can influence its adoption by physi-
cians and other health care providers (Lee and Waldman, 1986~. The advantages
of a new technology compared with those of currently available technology are
important in establishing the level and speed of its acceptance. When financial
Knowledge
| Innovation l
| Characteristics | Awareness
Judgment
1
Physician Decision
Characteristics / \
communication
data processing
motivation
Trial No Trial
/ \
\~` ~environment
I > Adopt Don't Adopt
Evaluation
FIGURE 5-1 Conceptual model of the diffusion of innovation to physicians.
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74
A. MARK FENDRICK AND J. SANFORD SCHWARTZ
incentives are neutral "breakthrough" technologies, such as antibiotics for bacte-
rial infections or chemotherapy for childhood malignancies, are likely to be
adopted more rapidly than "me-too" innovations, such as an additional entry into
a class of established pharmaceutical drugs that can offer only marginal benefits
over the drugs currently in use (Warner, 1975~.
The adoption and diffusion of a technology are also a function of the re-
sources and organizational commitment necessary to experiment with the inno-
vation (Baker, 1979; Hillman and Schwartz, 1986~. As a rule of thumb, the
fewer resources required to implement a change, the greater likelihood that adop-
tion of that innovation will occur. Pharmaceutical agents and many diagnostic
tests do not require large capital investments, organizational change, or physical
plant alterations, and therefore are easily tried out by physicians. In contrast,
interventions that require substantial financial expenditures or training of skilled
personnel to acquire proficiency (e.g., magnetic resonance imaging scanners)
necessitate a complicated decisionmaking process, which may inhibit the rate of
adoption of that intervention. All other factors being equal, less expensive or
more profitable innovations will tend to replace existing technologies that pro-
duce similar outcomes.
Provider Characteristics
Because the resources that can be devoted to health care are not infinite,
physicians are now being charged with a complex and sometimes inherently
contradictory set of responsibilities. On the one hand, physicians' primary re-
sponsibility is to provide the necessary services to optimize their patients' health.
On the other hand, as health care costs continue to increase providers are required
to incorporate economic principles into their clinical practices. As a result, the
physician's role has expanded beyond that of the doctor-patient relationship
(Mulley, 1992; Williams, 1992~.
The most important role of the physician is serving the patient. Ideally,
physicians successfully act as their patients' agents, providing the care that pa-
tients would choose if the patients possessed the scientific knowledge and judg-
ment that the physicians possess. In this role, ideally, the physician's decision to
adopt an innovation would focus on an individual patient's outcome and not on
those outcomes of more interest to society.
It is known, however, that physicians are not perfect agents. Physician be-
havior is influenced by a number of factors in addition to patient outcomes. As
rational individuals, physicians seek to optimize personal gratification (the sec-
ond role of the physician), and the benefits realized from being "on the cutting
edge" may play a role in an individual's adoptive behavior by contributing to
their personal satisfaction. Other personal characteristics may affect their likeli-
hood of adopting new technologies. For example, younger physicians often adopt
innovative interventions more quickly than their older counterparts. Independent
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PHYSICIANS' DECISIONS REGARDING ACQUISITION OF TECHNOLOGY 75
of physician age, an inverse correlation exists between the time since completion
of medical training and the adoption of medical innovation. Speaking broadly,
adoption of a new technology is more rapid among subspecialists than general-
ists, group practitioners than solo practitioners, and urban providers than those
practicing in rural settings. Physicians with academic or national affiliations also
have a greater proclivity to adopt and use new technology than do those without
them (Freiman, 19851. As provider reimbursements are constrained and compe-
tition for patients increases, market factors may also stimulate physicians to adopt
medical innovations more quickly (Hillman et al., 1989; McCarthy, 1985; Wilen-
sky and Rossiter, 19831. Thus, physicians who are most subject to competitive
processes (e.g., those in urban locations) can be expected to adopt innovations
earlier. Although postulated, and surely present to some degree, proof of these
behaviors has yet to be quantified.
A third and increasingly important role of physicians is that of allocator of
scarce resources. However, it is inherently difficult to apply societal concerns on
the level of the doctor-patient relationship. Practitioners have limited exposure
to the formal training in decisionmaking analysis required to effectively integrate
societal perspectives into day-to-day clinical decisions. Increased attention by
providers to this underemphasized role would lead to improved efficiency in the
delivery of medical care services.
Knowledge
Technologies are evaluated along a number of dimensions: safety, efficacy,
effectiveness, and economic impact as well as those related to legal, ethical, and
societal concerns. The methodologies used in outcomes research differ in terms
of validity, reliability, and rigor; and studies vary in terms of populations exam-
ined, sample size, inclusion and exclusion criteria, and study site. The random-
ized controlled trial, often referred to as the "gold standard" of investigative
methods, is performed infrequently, except when mandated by regulatory author-
ities (e.g., the Food and Drug Administration tFDA]~. Regardless of the source
of the outcomes data, limitations exist regarding the usefulness of the resultant
information. Because of the rapid evolution of medical innovations, changes
occur in the real and perceived values of benefit and cost parameters and, more-
over, there are difficulties generalizing assessments of efficacy (measured under
optimal operating conditions) to effectiveness (measured under average operat-
ing conditions).
Much of the effectiveness research in use today reports surrogate out-
comes which are imperfectly associated with the outcomes of true interest as
study endpoints. This reliance on proxy measures is most likely a function of (1)
the lack of available research instruments, (2) the complexities of the necessary
analyses, and (3) an unwillingness to wait for data on the true outcomes of inter-
est, which often take years and whose generation requires great expense.
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A. MARK FENDRICK AND J. SANFORD SCHWARTZ
The disadvantages of the use of surrogate outcomes are well illustrated by
the case of thrombolytic therapy used in the setting of an acute myocardial in-
farction. The prices of the available thrombolytic agents differed approximately
tenfold. At the time of FDA approval, there were no direct comparative studies
on reinfarction rates, patient morbidity, or the primary outcome of interest
reduction in the rate of mortality rate from acute myocardial infarction. Rather,
certain agents were demonstrated to clear the clot in the coronary artery (felt to
be the etiology of the infarction) more quickly. Dissemination of the findings
reporting these surrogate outcomes led half of the users of one agent to switch to
the perceived "better," and more costly drug, and thousands more, who had be-
come convinced of the effectiveness of thrombolytic therapy, began using it
almost exclusively. Only recently have randomized trials compared the three
most frequently used agents head to head (ISIS-3 Collaborative Group, 1992~.
Results from the study of over 40,000 cases of acute myocardial infarction sug-
gest that the three agents have equal efficacies in terms of saving lives from acute
myocardial infarction. Despite the wide differential in price and the lack of
evidence suggesting an added clinical benefit from any particular thrombolytic
therapy, in the United States there appeared to be continued widespread use of
those agents with lower cost-effectiveness ratios.
In the published literature, there appears to be a positive bias toward studies
that promote the adoption of new technologies and a negative bias toward those
studies that recommend the "disadoption" of accepted interventions. Rarely will
physicians do something that they feel is against a patient's interest. But if an
additional intervention that is thought to benefit a patient becomes available, no
matter how small a benefit or how great the expenditure, there is a likelihood that
a provider will try it (the "technological imperatively. On the other hand, it is
difficult to get physicians to stop doing something they are comfortable doing on
the basis of a study that is not directly applicable to their day-to-day practice
(e.g., delivery by cesarean section) (Goyert et al., 1989~. Thus, the adoption of
medical innovations may have a long-lasting impact and may be difficult to
reverse (Eisenberg et al., 1989~.
Awareness
The effectiveness data generated from well-designed and well-conducted
outcomes studies is necessary, but not sufficient, for understanding physician
adoption decisions. Once effectiveness data are available, physicians must be-
come aware of them. A number of communications channels are now used to
convey information regarding health care services and medical innovations. The
pertinent issue is not how the message is sent, but how physicians assess the
quality of its content.
Inconsistencies exist in the dissemination of knowledge (Winkler et al.,
19851. Peer-reviewed medical journals occupy a central role in communicating
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PHYSICIANS' DECISIONS REGARDING ACQUISITION OF TECHNOLOGY 77
the risks and benefits of medical innovations to physicians. However, more
informal communications techniques (e.g., scientific meetings, continuing medi-
cal education courses, the views of opinion leaders, discussions with peers) are
also important ways for physicians to learn of technological advances (Fineberg
et al., 1978; Manning and Denson, 1979; McLaughlin and Penchansky, 1965;
Stross and Harlan, 1978~. Physicians demonstrate a pattern of preference in how
they receive information pertaining to medical innovation (Coleman et al., 1966;
Manning and Denson, 1980; Stross and Harlan, 1979~. They appear to place
greater value on information acquired from personal interactions, especially those
with local opinion leaders (Coleman et al., 1966, Williamson et al., 19891. More
recently, scientific advances are also being heralded by the lay press, which
directs its messages at both patients and providers.
Speed in reporting medical innovation is a double-edged sword, resulting in
a trade-off between the slower, more methodical process geared at ensuring sci-
entific fact that is exemplified by peer-reviewed journals, and the far swifter, less
definitive process represented by the mass media whose aim is to provide instant,
if not totally reliable, information ("newsy. If left solely to the peer review
process, the dissemination of innovation would be slowed. However, this con-
trolled method does appear better fit to meet the goals of a health care delivery
system devoted to determining the risks and benefits associated with an innova-
tion prior to its widespread diffusion. Without evaluation of this type, the (basi-
cally irreversible) implementation of innovation would proceed without a guar-
antee of the safety and efficacy associated with its use.
However, the effects of bypassing the peer-reviewed reporting process on the
adoption of technology, health outcomes, and resource use has yet to be determined.
Reporting in the lay press should not be viewed as an exclusively negative influ-
ence; use of the mass media can lead to increased awareness of effective underuti-
lized technologies and lead to societal health gains (e.g., immunization informa-
tion programs) (Herlitz et al., 1989~.
The lay press and word of mouth among patients were major forces behind
the rapid and widespread adoption of laparoscopic cholecystectomy. These me-
dia claimed that the procedural innovation produced excellent surgical results,
while providing the following advantages to the patient and the payer over con-
ventional open surgery: less pain, shorter hospital length of stay, and decreased
recovery time (Southern Surgeons Club, 1991~. Over half of the general sur-
geons in the United States invested time and resources to learn the technique,
even though controlled clinical trials comparing the laparoscopic technique to
available treatments had not been performed (White, 19921. It seems clear that
the popularity of laparoscopic cholecystectomy did not result from the usual
scientific discourse. Factors such as intense patient demand, competition among
general surgeons for the cholecystectomy "market," and vigorous marketing ef-
forts by surgical device manufacturers played important roles in the remarkably
rapid adoption of this innovation (Gelijns and Fendrick, 1993~.
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A. MARK FENDRICK AND J. SANFORD SCHWARTZ
Direct public advertising of products available only with a physician's pre-
scription is a recent phenomenon affecting providers' awareness of innovations.
The resultant effects on patient demand for services and physician awareness of
advertised products have yet to be quantified. The use of information systems
such as television broadcasting (e.g., Lifetime network on cable television), con-
tinuing medical education courses, on-line databases (e.g., Medline), or clinical
decisionmaking software packages may also improve physicians' access to infor-
mation about emerging technologies.
Despite these multiple avenues of communication, it is not possible for an
individual practitioner to keep abreast of every event that has a clinical conse-
quence of potential interest (Stinson and Mueller, 1980~. An example of a failure
to appropriately communicate information of an effective medical intervention is
the case of the treatment of diabetic retinopathy, the most common cause of
severe vision loss among those of working age (Kohner and Barry, 1984~. The
Diabetic Retinopathy Study was a randomized controlled trial which demonstrat-
ed that timely treatment of diabetic retinopathy reduced by one-half severe vision
loss in the diabetic population (Diabetic Retinopathy Study Research Group,
1976~. But the results from this trial were published in the ophthalmology litera-
ture, sources that are not widely read by primary-care practitioners, who provide
the majority of medical care to individuals with diabetes (Stross and Harlan,
19791. Thus, a majority of providers went unaware of the research findings and
individuals with diabetes suffered unnecessary morbidity simply because of a
failure to effectively disseminate the findings of this carefully conducted investi-
gation.
In an effort to improve the dissemination of the results of outcomes research,
a special program has been established by the Agency for Health Care Policy and
Research to study the different methods of effectively communicating informa-
tion regarding medical innovations to physicians. More studies are needed on the
dissemination of information on medical innovations by both the scientific com-
munity and the mass media. Greater emphasis on safety, efficacy, effectiveness,
and cost and less focus on unproven benefits may turn out to improve the effi-
ciency, but slow the rate, of adoption of medical innovation by physicians.
Judgment
Technology itself is not the culprit for the high cost of medical care; rather, it
is society's current inability to make and enforce decisions about what medical
services it needs and can afford (Schroeder and Showstack, 1979~.
Political, social, and legal influences have a direct impact on the failure to
efficiently allocate spending on our health care resources, estimated to approach
$1 trillion in 1993. The generation and dissemination of scientific knowledge are
only a few of the necessary pieces to the health care delivery puzzle. Once data
on the value of an innovation are available, physicians must synthesize the infor
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PHYSICIANS' DECISIONS REGARDING ACQUISITION OF TECHNOLOGY 79
mation and pass judgment on whether the technology is worthy of a trial on their
patients. A number of external factors influence this decision. The adoptive
behaviors of local peers (and competitors) appear to be the most important pre-
dictor of whether an individual physician will try an innovation. Also important
are the decisions of regulatory agencies and recommendations of national, pro-
fessional, and scientific organizations (Lomas et al., 1989~.
A hurdle often encountered by physicians in deciding whether or not to try
an innovation is the generalizability of results from published clinical trials to
individual patients. Research studies have carefully specified inclusion and ex-
clusion criteria. These criteria commonly exclude many patients who are poten-
tially eligible for the innovation once it receives regulatory approval. Thus,
physicians must extrapolate the results of clinical trials (efficacyJ to routine clini-
cal practice (effectiveness). This problem may account for the enduring accep-
tance of anecdotal experience (outcomes related to personal experience) by phy-
sicians, one of the least rigorous methods of evaluation.
Trial
Once a positive judgment is made, a trial of the innovation must be under-
taken. The propensity to try an innovation is directly related to the ease of
experimentation. The lower the investment of time, effort, risk and resources
involved in trying an innovation, the more likely a physician will experiment
with it (see the section Innovation CharacteristicsJ. For example, the adoption
threshold is likely to be lower for new pharmaceuticals than for new surgical
procedures because it is far easier and convenient to write a prescription than to
obtain the proficiency (and perhaps the credentials) for performing the surgery.
Again, local practices exert a significant amount of influence on an individual
physician's decisionmaking, illustrating that what is happening in one's own
backyard is often more important than national trends.
In the competitive environment for physicians in the 1990s, delayed adop-
tion of a popular innovation that has been touted through the mass media (with or
without evidence of its effectiveness) may lead to the loss of patients. This
concern over the loss of market share stimulated the adoption of computed to-
mography and magnetic resonance imaging scanners by hospitals (Baker, 1979;
Creditor and Garrett, 1977; Ramsey et al., 1993~. Other environmental factors,
such as the fear of malpractice litigation, may affect the rates of adoption of
medical innovation. On the one hand, these factors may drive adoption if a new
intervention becomes perceived as a "standard of care," even in the absence of
rigorous scientific evidence (e.g., as happened with fetal monitoring). On the
other hand, they may inhibit diffusion, for example, obstetricians (who have
higher-than-average malpractice claims and insurance rates) adopt new proce-
dures at a slower pace than other clinical specialists do (Freiman, 19854.
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A. MARK FENDRICK AND J. SANFORD SCHWARTZ
Adoption
After a positive trial comes the decision regarding adoption. One of the
more important factors influencing adoption of medical innovations by physi-
cians is reimbursement policy. History reveals a pattern of "no pay, no play" by
physicians. If fair payment for the use of an innovation cannot be guaranteed,
this disincentive alone may delay or retard the eventual acceptance of an innova-
tion (e.g., as happened with cochlear implant for severe hearing impairment).
Conversely, the ease of establishing reimbursement for the use of a medical
innovation can speed its adoption and diffusion. The spectacular diffusions of
both laparoscopic cholecystectomy and percutaneous transluminal coronary an-
gioplasty were facilitated by the fact that physicians could be paid for these new
procedures under existing, profitable reimbursement codes for open cholecystec-
tomy and coronary artery bypass grafting (Gelijns and Fendrick, 1993~.
With rare exceptions, drugs are automatically reimbursed by payers follow-
ing approval by the FDA. This practice has, however, recently come under
scrutiny by insurance companies fearful of the potential overuse of expensive
agents shown in efficacy testing to be of marginal benefit for limited clinical
indications. In certain instances, reimbursement may not be provided for expen-
sive FDA-approved agents used for indications other than those specifically ap-
proved by the FDA. For diagnostic tests and devices, a less straightforward
reimbursement pattern exists that is more dependent on the payers' particular
decisionmaking processes. For example, it was not until six months after the
approval of magnetic resonance imaging by the FDA that the Health Care Fi-
nancing Administration announced reimbursement of this imaging technique for
Medicare recipients. Only then did the diffusion of magnetic resonance units
accelerate (Ramsey et al., 1993~.
Administrative and bureaucratic factors such as peer review processes, cer-
tificate-of-need legislation, and credentialing requirements may have either posi-
tive or negative effects on the adoption of a new technology by physicians (Me-
chanic, 1977, Russell, 1976~. Restricting the use of an innovation (e.g.,
antibiotics) by instituting a formal process may prevent unnecessary usage and
slow adoption. Such a process typically draws on the experience of a specialist
physician with expertise in the indications for using the innovation. At the same
time, providing a streamlined administrative system for patients to receive effec-
tive interventions (e.g., thrombolytic therapy) may increase the level of adoption
and use of an innovation and have a positive effect on patient outcomes (Topol et
al., 1987~.
Evaluation
A physician's decision to adopt a medical innovation is usually reversible.
With each opportunity for use, a decision based on experience and the tincture of
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PHYSICIANS' DECISIONS REGARDING ACQUISITION OF TECHNOLOGY 81
time is made by the physician regarding the appropriateness of an innovation.
Many factors, such as ease of patient selection and opportunities for continued
use, will directly influence the longevity of a medical intervention (Banta et al.,
1981~. Concern over the early obsolescence of a technology can retard the initial
adoption of an innovation that is perceived to be easily replaced, eventually, by a
better alternative. This concern over early obsolescence is partly a function of
the resources committed to the technology (Kimberly, 1978~. The changing
nature of clinical practice allows for tremendous turnover in the equipment need-
ed to appropriately provide care and medical manufacturers seem happy to oblige
the evolving practice of modern medicine with a never-ending supply of tools.
SUMMARY
The understanding of physician adoption of medical innovation is incom-
plete. The use of conceptual models can help illustrate the complex decision-
making tasks physicians face when they are confronted with the opportunity to
adopt an innovative technology. Scientific knowledge on effectiveness and re-
source use is essential, but it is not a panacea for the resource allocation problem.
Numerous barriers prevent the incorporation of quality-enhancing, cost-effective
technologies into everyday clinical practice: method and content of communica-
tions, regulatory decisionmaking, reimbursement levels, malpractice claims, and
external micromanagement of clinical decisions, to name a few. At the same
time, the competitiveness of the U.S. medical care system provides incentives to
acquire innovations before proof of their relative usefulness in terms of patient
outcomes and cost-effectiveness is generated from rigorous evaluations. Thus,
an inconsistent pattern of adoption of innovation by physicians has developed.
Research in understanding physician adoption of an innovation should con-
tinue to play a significant role as the nation studies ways to reform the health care
delivery system. In addition to the development of clinical guidelines based on
outcomes research and medical appropriateness (e.g., the Patient Outcomes Re-
search Team initiative funded by the Agency for Health Care Policy and Re-
search), research in other areas that affect physician behavior warrant increased
attention as well. Objectives of this additional effort should be to (1) focus on
research that is generalizable to everyday clinical practice, (2) ensure that re-
search findings are disseminated quickly and to all applicable parties in under-
standable language, and (3) provide incentives financial and other to reward
the effective and penalize the ineffective behaviors of all stakeholders.
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Representative terms from entire chapter:
medical innovations
