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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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76 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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78 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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80 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. REFERENCES Altman, S. H., and Blendon, R. J., eds. 1979. Medical Technology: The Culprit Behind Health Care Costs? Washington, D.C.: U.S. Government Printing Office.

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82 A. MARK FENDRICK AND J. SANFORD SCHWARTZ Baker, S. R. 1979. The diffusion of high technology medical innovation: The computed tomography scanner example. Social Science & Medicine 13D:155-162. Banta, H. D., Behney, C. J., and Willems, J. S. 1981. Toward Rational Technology in Medicine: Considerations for Health Policy. New York, N.Y.: Springer. Chalmers, T. C. 1974. The impact of controlled trials on the practice of medicine. Mount Sinai Journal of.~edicine 41:753-759. Coleman, J. S., Katz, E., and Menzel, H. 1966. Medical Innovation: A Diffusion Study. New York, N.Y.: Bobbs-Merrill Company. Creditor, M. C., and Garrett, J. B. 1977. The information base for diffusion of technol- ogy: Computed tomography scanning. New England Journal of Medicine 297:49- 52. Diabetic Retinopathy Study Research Group. 1976. Preliminary report of the effects of photocoagulation therapy. American Journal of Ophthalmology 81:383-396. Eisenberg, J. M. 1986. Doctor's Decisions and the Cost of Medical Care. Ann Arbor, Mich.: Health Administration Press. Eisenberg, J. M., and Williams, S. V. 1981. Cost containment and changing physician's practice behavior: Can the fox learn to guard the chicken coop? Journal of the American Medical Association 246:2195-2201. Eisenberg, J. M., Schwartz, J. S., McCaslin, F. C., et al. 1989. Substituting diagnostic services: New tests only partly replace older ones. Journal of the American Medical Association 262:1196-1200. Fineberg, H. V., and Hiatt, H. H. 1979. Evaluation of medical practices: The case for technology assessment. New England Journal of Medicine 301:1086-1091. Fineberg, H. V., Gabel, R. A., and Sosman, M. B. 1978. Acquisition and application of new medical knowledge by anesthesiologists. Anesthesiology 48:430-436. Freiman, M. P. 1985. The rate of adoption of new procedures among physicians: The impact of specialty and practice characteristics. Medical Care 23:939-945. Fuchs, V. 1968. The growing demand for medical care. New England Journal of Medi- cine 279: 190-195. Gelijns, A. C., and Fendrick, A. M. 1993. The dynamics of innovation in minimally invasive therapy. Health Policy 23:153-166. Goyert, G. L., Bottoms, S. F., Treadwell, M. C., et al. 1989 The physician factor in Cesarean birth rates. New England Journal of Medicine 320:70~709. Greer, A. L. 1977. Advances in the study of diffusion of innovation in health care organizations. Milbank Memorial Fund Quarterly 55:505-532. Greer, A. L. 1988. The state of the art versus the state of the science: The diffusion of new medical technologies into practice. International Journal of Technology Assess- ment in Health Care 4:5-26. Hemenway, D., Killen, A., Cashman, S. B., et al. 1990. Physicians' responses to finan- cial incentives: Evidence from a for-profit ambulatory care center. New England Journal of Medicine 322: 1059-1063. Herlitz, J., Hartford, M., Blohm, M., et al. 1989. Effect of a media campaign on delay times and ambulance use in suspected acute myocardial infarction. American Jour- nal of Cardiology 64:90-93. Hichson, G. B., Altemeier, W. A., and Perrin, J. M. 1987. Physician reimbursement by salary or fee for service: Effect on physician practice behavior in a randomized prospective study. Pediatrics 80:34~350.

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