Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in health care

Background: Although innovation can improve patient care, implementing new ideas is often challenging. Previous research found that professional attitudes, shaped in part by health policies and organisational cultures, contribute to differing perceptions of innovation ‘evidence’. However, we still know little about how evidence is empirically accessed and used by organisational decision-makers when innovations are introduced. Aims and objectives: We aimed to investigate the use of different sources and types of evidence in innovation decisions to answer the following questions: how do managers make sense of evidence? What role does evidence play in management decision-making when adopting and implementing innovations in health care? How do wider contextual conditions and intraorganisational capacity influence research use and application by health-care managers? Methods: Our research design comprised multiple case studies with mixed methods. We investigated technology adoption and implementation in nine acute-care organisations across England. We employed structured survey questionnaires, in-depth interviews and documentary analysis. The empirical setting was infection prevention and control. Phase 1 focused on the espoused use of evidence by 126 non-clinical and clinical hybrid managers. Phase 2 explored the use of evidence by managers in specific technology examples: (1) considered for adoption; (2) successfully adopted and implemented; and (3) rejected or discontinued. Findings: (1) Access to, and use of, evidence types and sources varied greatly by profession. Clinicians reported a strong preference for science-based, peer-reviewed, published evidence. All groups called upon experiential knowledge and expert opinion. Nurses overall drew upon a wider range of evidence sources and types. Non-clinical managers tended to sequentially prioritise evidence on cost from national-level sources, and local implementation trials. (2) A sizeable proportion of professionals from all groups, including experienced staff, reported difficulty in making sense of evidence. Lack of awareness of existing implementation literature, lack of knowledge on how to translate information into current practice, and lack of time and relevant skills were reported as key reasons for this. (3) Infection outbreaks, financial pressures, performance targets and trusted relationships with suppliers seemed to emphasise a pragmatic and less rigorous approach in sourcing for evidence. Trust infrastructure redevelopment projects, and a strong emphasis on patient safety and collaboration, appeared to widen scope for evidence use. (4) Evidence was continuously interpreted and (re)constructed by professional identity, organisational role, team membership, audience and organisational goals. (5) Doctors and non-clinical managers sourced evidence plausible to self. Nursing staff also sought acceptance of evidence from other groups. (6) We found diverse ‘evidence templates’ in use: ‘biomedical-scientific’, ‘practice-based’, ‘rational-policy’. These represented shared cognitive models which defined what constituted acceptable and credible evidence in decisions. Nurses drew on all diverse ‘templates’ to make sense of evidence and problems; non-clinical managers drew mainly on the practice-based and rational-policy templates; and doctors drew primarily on the biomedical-scientific template. Conclusions: An evidence-based management approach that inflexibly applies the principles of evidence-based medicine, our findings suggest, neglects how evidence is actioned in practice and how codified research knowledge inter-relates with other ‘evidence’ also valued by decision-makers. Local processes and professional and microsystem considerations played a significant role in adoption and implementation. This has substantial implications for the effectiveness of large-scale projects and systems-wide policy

Lymphovascular and perineural invasion as selection criteria for adjuvant therapy in intrahepatic cholangiocarcinoma: a multi-institution analysis

AbstractObjectivesCriteria for the selection of patients for adjuvant chemotherapy in intrahepatic cholangiocarcinoma (IHCC) are lacking. Some authors advocate treating patients with lymph node (LN) involvement; however, nodal assessment is often inadequate or not performed. This study aimed to identify surrogate criteria based on characteristics of the primary tumour.MethodsA total of 58 patients who underwent resection for IHCC between January 2000 and January 2010 at any of three institutions were identified. Primary outcome was overall survival (OS).ResultsMedian OS was 23.0months. Median tumour size was 6.5cm and the median number of lesions was one. Overall, 16% of patients had positive margins, 38% had perineural invasion (PNI), 40% had lymphovascular invasion (LVI) and 22% had LN involvement. A median of two LNs were removed and a median of zero were positive. Lymph nodes were not sampled in 34% of patients. Lymphovascular and perineural invasion were associated with reduced OS [9.6months vs. 32.7months (P= 0.020) and 10.7months vs. 32.7months (P= 0.008), respectively]. Lymph node involvement indicated a trend towards reduced OS (10.7months vs. 30.0months; P= 0.063). The presence of either LVI or PNI in node-negative patients was associated with a reduction in OS similar to that in node-positive patients (12.1months vs. 10.7months; P= 0.541). After accounting for adverse tumour factors, only LVI and PNI remained associated with decreased OS on multivariate analysis (hazard ratio4.07, 95% confidence interval 1.60–10.40; P= 0.003).ConclusionsLymphovascular and perineural invasion are separately associated with a reduction in OS similar to that in patients with LN-positive disease. As nodal dissection is often not performed and the number of nodes retrieved is frequently inadequate, these tumour-specific factors should be considered as criteria for selection for adjuvant chemotherapy

Duodenal carcinoma at the ligament of Treitz. A molecular and clinical perspective

Background There is very small occurrence of adenocarcinoma in the small bowel. We present a case of primary duodenal adenocarcinoma and discuss the findings of the case diagnostic modalities, current knowledge on the molecular biology behind small bowel neoplasms and treatment options. Case The patient had a history of iron deficiency anemia and occult bleeding with extensive workup consisting of upper endoscopy, colonoscopy, capsule endoscopy, upper gastrointestinal series with small bowel follow through and push enteroscopy. Due to persistent abdominal pain and iron deficiency anemia the patient underwent push enteroscopy which revealed adenocarcinoma of the duodenum. The patient underwent en-bloc duodenectomy which revealed T3N1M0 adenocarcinoma of the 4th portion of the duodenum. Conclusions Primary duodenal carcinoma, although rare should be considered in the differential diagnosis of occult gastrointestinal bleeding when evaluation of the lower and upper GI tract is unremarkable. We discuss the current evaluation and management of this small bowel neoplasm

Unpacking ostensive and performative aspects of organisational routines in the context of monitoring systems: a critical realist approach

Drawing on the theory of organisational routines as generative systems, we deploy a critical realist approach based on Searle's philosophy of language to analyse the generative mechanisms that specify the pre-conditions for recognisable, repetitive patterns of interdependent activities. Using the example of the organisational routines implemented in Germany to monitor the allocation and disbursement of the European Social Fund, we contend that constitutive rules of the type "X counts as Y in context C" are at the very centre of organisational routines. Such rules consist of generative mechanisms that account for the emergence of the ostensive aspects of organisational routines out of artefacts and/or procedures in a social structure of power relations. We further claim that, far from being proxies for the ostensive aspects of routines, artefacts whether tangible or intangible are instantiations of such ostensive aspects on a par with any other performative aspects of routines. On this basis, a re-conceptualisation and a re-labelling of the ostensive and performative aspects of routines are proposed. The former are the result of the activation of systems of constitutive rules, i.e. actual routines in critical realist terminology, the latter are patterns of interdependent activities instantiating the ostensive aspects of routines, i.e. empirical routines in critical realist terminology. Implications for theory and practice are discussed by developing a model of organisational routines that interweaves extant research streams. © 2011 Elsevier Ltd

Clinical Score Predicting Long-Term Survival after Repeat Resection for Recurrent Adrenocortical Carcinoma.

BackgroundAdrenocortical carcinoma (ACC) is an aggressive malignancy typically resistant to chemotherapy and radiation. Surgery, even in the setting of locally recurrent or metastatic disease, remains the only potentially curative option. However, the subset of patients who will benefit from repeat resection in this setting remains ill defined. The objective of this study was to propose a prognostic clinical score that facilitates selection of patients for repeat resection of recurrent ACC.Study designPatients who underwent curative-intent repeat resection for recurrent ACC at 1 of 13 academic medical centers participating in the US ACC Study Group were identified. End points included morbidity, mortality, and overall survival.ResultsFifty-six patients underwent repeat curative-intent resection for recurrent ACC (representing 21% of 265 patients who underwent resection for primary ACC) from 1997 to 2014. Median age was 52 years. Sites of resected recurrence included locoregional only (54%), lung only (14%), liver only (12%), combined locoregional and lung (4%), combined liver and lung (4%), and other distant sites (12%). Thirty-day morbidity and mortality rates were 40% and 5.4%, respectively. Cox regression analysis revealed that the presence of multifocal recurrence, disease-free interval <12 months, and extrapulmonary distant metastases were independent predictors of poor survival. A clinical score consisting of 1-point each for the 3 variables demonstrated good discrimination in predicting survival after repeat resection (5-year: 72% for 0 points, 32% for 1 point, 0% for 2 or 3 points; p = 0.0006, area under the curve = 0.78).ConclusionsLong-term survival after repeat resection for recurrent ACC is feasible when 2 of the following factors are present: solitary tumor, disease-free interval >12 months, and locoregional or pulmonary recurrence