Saving Women's Lives Strategies for Improving Breast Cancer Detection and Diagnosis (2005) / Chapter Skim
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7 Translating New Technologies into Improved Patient Outcomes
7 Translating New Technologies into Improved Patient Outcomes
Pages 249-268
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From page 249... ...
decisions by healthcare delivery organizations to adopt these new technologies that are based on assessment of the efficacy and cost-effectiveness of the technologies, (2) deployment of these technologies within the complex organizational structure of healthcare providers, and (3)
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But far fewer plan systematically for the organizational, technological, and other complementary requirements for the deployment of these technologies. Even fewer healthcare delivery organizations, in the judgment of this Committee, invest sufficiently in the monitoring of the use and effectiveness of these technologies as employed by healthcare practitioners.
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Practitioner exper TABLE 7-1 The Three Phases of Technology Adoption Phase Definition/ Examples Technology assessment Evaluation of the results of scientific testing of a technology: · Cost-benefit analysis* · Efficacy · Specification of the target population Technology deployment Putting technology into practice: · Early experience and learning · Development of new work routines · Integration with existing technologies and work routines Technology monitoring Post-application monitoring: · Evaluation of outcomes · Detection of anomalies *
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All but the first phases of technology adoption are typically undertaken by healthcare delivery organizations that are planning widespread use of a technology (although some provider organizations also conduct their own technology assessment in addition to those undertaken by the FDA and Centers for Medicare & Medicaid Services [CMS]
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The complexity of technology adoption is likely to be further increased by the reduction in size of patient populations as smaller risk groups are successfully identified, each possibly requiring a different screening strategy and suite of screening technologies. This approach could be less complicated when used by an integrated health care team that provides all aspects of a breast cancer diagnosis.
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Another important factor that is particularly relevant to breast cancer detection technologies is complexity. BOX 7-2 Typology of Technology Adopters The fastest individuals or groups to adopt new technologies are the innova tors who tend to be wealthier than average or otherwise able to accept the risks and costs inherent in innovation.
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Definitive clinical trials of thermography have never been conducted to determine its effectiveness in detection breast cancer and no thermographic devices have gained widespread clinical acceptance. Therefore, it should not be surprising that FDA approval is no guarantee that a technology will be widely adopted.
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In certain cases, such as for BRCA testing or other "home-brew" tests, FDA approval is not even necessary. The FDA does not regulate the BRCA test, because the test kits are not marketed to consumers and do not claim to produce a beneficial clinical outcome.
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From page 257... ...
For example, sever al cheaper tests with similar effectiveness have been developed, yet the broad scope of Myriad's patent prevents health care systems worldwide from adopting other technologies.21 For instance, a faster and cheaper genetic test cannot be offered locally within a system of care that is linked to genetic counseling services and the other testing services offered by the system, thus restricting access to care.25 Testing begun in the Canadian province of Ontario for a third of the cost of Myriad's test and with results available eight weeks sooner, was threatened with legal action by Myriad against the province of Ontario in late 2002. However, under the direction of Ontario's Health Minister Tony Clement, regional hospitals have disregarded the patent and continue to offer BRCA gene testing services.
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Although CMS will reimburse health care providers for the use of digital mammography for screening mammograms, many insurance companies will not. The Blue Cross Blue Shield Technology Evaluation Center and the Kaiser Foundation Health Plan have both decided not to cover digital mammography, because it has not been demonstrated that:5 · It improves net health outcomes, · It is as beneficial as screen-film mammography, and · It improves outcomes outside investigational settings (i.e., in rou tine clinical practice)
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Drug eluting stents are coated with a polymer containing a drug that is released into the surrounding tissue to prevent scar tissue formation. earlier, there are many drivers to technology adoption, including patients who pay out of pocket for new technologies.
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Many patients with advanced disease had been told at cancer centers that this treatment had shown promise.23 In the meantime, more than 15,000 women with invasive breast cancer had been treated with HDC/BMT, a grueling treatment that involved weeks of isolation in extreme pain.15 Void-Filling Technologies Are Adopted More Readily When mammography was introduced, it was a "void-filling" technology and thus had no competition during the adoption process. New imaging technologies for breast cancer detection face a different scenario.
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In contrast, other technologies such as blood tests that could reliably and accurately identify breast cancer risk or that could distinguish among potentially invasive and noninvasive cancer would be void-filling technologies and would be expected to be readily adopted. BRCA testing and protein profiling based on microarray analysis are both examples of void-filling technologies.
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From page 262... ...
, · Whether there is recognition or demand for it, and · Promotional initiatives. For example, a study that compared the ability of different surgical teams to adopt minimally invasive procedure for cardiac surgery found that their proficiency was linked to their ability to adopt new work routines and relationships among surgical team members (Box 7-6)
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The successful adoption of this approach re quired members of the surgical team to learn new tasks, establish new routines, and -- most importantly -- develop ways of working together that differed consider ably from their experience in performing conventional cardiac surgery. A Harvard research team compared the adoption of the minimally invasive procedure among 16 different cardiac surgical units, using the amount of time taken to complete a coronary artery bypass graft (CABG)
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The project was started in 1996 in response to quality assessments indicating that detectable breast cancers were being misdiagnosed by several radiologists. It incorporated many innovations in healthcare delivery, including patient safety, continuous quality improvement, and development of practice focus within the specialty of radiology specific to mammography.
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· From the inception of the comprehensive quality monitoring pro cess, individual and group results have been fed back to the radi ologists. Data are compared to published benchmarks, goals of group performance and individual variation are defined, perfor mance gaps analyzed, specific interventions applied, and the results of interventions measured.
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During the study period the cost of the professional component relative value unit for each mammogram declined 45 percent, and is now approximately $28, which is 77 percent of the Medicare benchmark. Technology monitoring was integral to this project: first, in the recognition that there was room for improvement, and then throughout the project by establishing monitoring as a routine part of the organization.
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5. Blue Cross Blue Shield Association.
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2001. Organizational differences in rates of learning: evidence from the adoption of minimally invasive cardiac surgery.
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