Lost in translation? : negotiating technological innovation in healthcare

Technological innovation in healthcare is growing at a rapid pace. Developments in genetics, stem cell research, bioinformatics, imaging and screening techniques have broadened out the arena of health technology. These developments in sophisticated technology, it is suggested, have the potential to revolutionize the practices of medicine and healthcare by providing more proactive and powerful tools for the diagnosis, treatment, and prevention of illness and disease (Liddell et al, 2008; Webster, 2002). In support of such claims, available research findings suggest that the adoption of new innovative health technologies (IHTs) can result in reducing healthcare costs, increasing productivity, healthcare effectiveness, and improving the patient’s experience of care by better management of chronic diseases (Liddell et al, 2008; Healthcare Industries Task Force, 2004). At the same time, new innovative health technologies present many challenges. Evidence indicates that patient safety and proven clinical effectiveness are insufficient to ensure the adoption and implementation of new clinical technologies. The prevailing organizational and policy context is crucially important as this may present barriers which slow or even prevent uptake (Lehoux 2006). In recent years there has been a continuing debate around issues of clinical resistance, organizational/clinical restructuring, procurement and commissioning, public trust, and, more widely, around the ethical and social implications of techno-scientific innovations in medicine and health (Williams and Dickinson, 2008; Webster, 2006; Ferlie et al., 2005). Moreover, cost-effectiveness evidence is now required to inform decisions about the funding and procurement of new healthcare services and technologies (Fitzgerald et al., 2002). Overall, the value of the innovation has to be clearly evident to a number of different stakeholders if technologies are to be embedded into actual work practices. These potential barriers have given rise to questions related to the diffusion and adoption of emerging medical and healthcare innovations. This paper examines the dynamics and complexity of innovation adoption processes in the context of a rapidly changing healthcare policy landscape. Drawing upon the inherently socially negotiated character of meaning, this paper illustrates the ambivalent nature of technological innovation by examining the complex ongoing interplay of heterogeneous discourses in shaping the adoption of innovative health technologies (Law, 1987, 1994). Drawing upon Rye and Kimberly (2007) adoption is here understood as a distinct organizational process related to an organization’s potential interest in implementing a technological innovation. In so doing, this paper draws on the findings of a three year research project which examines the adoption of innovative clinical technologies in the UK NHS. In particular, we explore the nature, role and dynamics of heterogeneous discourses (technological, managerial/professional, clinical), in shaping the adoption of a retinal imaging technology in a UK hospital Trust. In this regard, we contribute to the development of alternative ways of describing, analysing, and theorizing the process of technological innovation in healthcare

Facilitating the implementation of clinical technology in healthcare : what role does a national agency play?

Background: Accelerating the implementation of new technology in healthcare is typically complex and multi-faceted. One strategy is to charge a national agency with the responsibility for facilitating implementation. This study examines the role of such an agency in the English National Health Service. In particular, it compares two different facilitation strategies employed by the agency to support the implementation of insulin pump therapy. Methods: The research involved an empirical case study of four healthcare organisations receiving different levels of facilitation from the national agency: two received active hands-on facilitation; one was the intended recipient of a more passive, web-based facilitation strategy; the other implemented the technology without any external facilitation. The primary method of data collection was semi structured qualitative interviews with key individuals involved in implementation. The integrated-PARIHS framework was applied as a conceptual lens to analyse the data. Results: The two sites that received active facilitation from an Implementation Manager in the national agency made positive progress in implementing the technology. In both sites there was a high level of initial receptiveness to implementation. This was similar to a site that had successfully introduced insulin pump therapy without facilitation support from the national agency. By contrast, a site that did not have direct contact with the national agency made little progress with implementation, despite the availability of a web-based implementation resource. Clinicians expressed differences of opinion around the value and effectiveness of the technology and contextual barriers related to funding for implementation persisted. The national agency’s intended roll out strategy using passive web-based facilitation appeared to have little impact. Conclusions: When favourable conditions exist, in terms of agreement around the value of the technology, clinician receptiveness and motivation to change, active facilitation via an external agency can help to structure the implementation process and address contextual barriers. Passive facilitation using web-based implementation resources appears less effective. Moving from initial implementation to wider scale-up presents challenges and is an issue that warrants further attention

A systematic review and narrative summary of family-based smoking cessation interventions to help adults quit smoking

Background: Smoking is the most significant preventable cause of morbidity and early mortality in the world. The family is an influential context in which smoking behaviour occurs. Methods: A systematic review and narrative summary of family-based interventions to help adults quit smoking was conducted. Results: Eight controlled trials were included. Risk of bias was high. The smoking-related outcome of the intervention was self-reported smoking status/abstinence, validated by objective measures (including saliva thiocynate or breath carbon monoxide). Follow-up ranged from six weeks to five years. The main target groups were: pregnant women (1), pregnant women who smoked (2), men at risk of cardiovascular disease (2), adult smokers (1), parents who smoked (1) and couples who both smoked (1). Interventions included family members but most did not go further by drawing on family, systemic or relational theories to harness the influence of family on smoking behaviour. Only three studies directly compared the effects on smoking behaviour of a family-based (i.e. interventions that involve a member of the family) versus an individual-based (i.e. interventions that use behaviour change techniques that focus on the individual) intervention. None of these studies found significant differences between groups on the smoking behaviour of the main target group. Conclusions: We have yet to develop family-based smoking cessation interventions that harness or re-direct the influence of family members on smoking behaviour in a positive way. Thus, it is likely that individualised-approaches to smoking cessation will prevail.Publisher PDFPeer reviewe

“Catch 22”: biosecurity awareness, interpretation and practice amongst poultry catchers

Campylobacter contamination of chicken on sale in the UK remains at high levels and has a substantial public health impact. This has prompted the application of many interventions in the supply chain, including enhanced biosecurity measures on-farm. Catching and thinning are acknowledged as threats to the maintenance of good biosecurity, yet the people employed to undertake this critical work (i.e. ‘catchers’) are a rarely studied group. This study uses a mixed methods approach to investigate catchers’ (n = 53) understanding of the biosecurity threats posed by the catching and thinning, and the barriers to good biosecurity practice. It interrogated the role of training in both the awareness and practice of good biosecurity. Awareness of lapses in biosecurity was assessed using a Watch-&-Click hazard awareness survey (n = 53). Qualitative interviews (n = 49 catchers, 5 farm managers) explored the understanding, experience and practice of catching and biosecurity. All of the catchers who took part in the Watch-&-Click study identified at least one of the biosecurity threats with 40% detecting all of the hazards. Those who had undergone training were significantly more likely to identify specific biosecurity threats and have a higher awareness score overall (48% compared to 9%, p = 0.03). Crucially, the individual and group interviews revealed the tensions between the high levels of biosecurity awareness evident from the survey and the reality of the routine practice of catching and thinning. Time pressures and a lack of equipment rather than a lack of knowledge appear a more fundamental cause of catcher-related biosecurity lapses. Our results reveal that catchers find themselves in a ‘catch-22′ situation in which mutually conflicting circumstances prevent simultaneous completion of their job and compliance with biosecurity standards

Ramucirumab for Treating Advanced Gastric Cancer or Gastro-Oesophageal Junction Adenocarcinoma Previously Treated with Chemotherapy

The National Institute for Health and Care Excellence (NICE) invited the company that manufactures ramucirumab (Cyramza®, Eli Lilly and Company) to submit evidence of the clinical and cost effectiveness of the drug administered alone (monotherapy) or with paclitaxel (combination therapy) for treating adults with advanced gastric cancer or gastro-oesophageal junction (GC/GOJ) adenocarcinoma that were previously treated with chemotherapy, as part of the Institute’s single technology appraisal (STA) process. Kleijnen Systematic Reviews Ltd (KSR), in collaboration with Erasmus University Rotterdam, was commissioned to act as the Evidence Review Group (ERG). This paper describes the company’s submission, the ERG review, and NICE’s subsequent decisions. Clinical effectiveness evidence for ramucirumab monotherapy (RAM), compared with best supportive care (BSC), was based on data from the REGARD trial. Clinical effectiveness evidence for ramucirumab combination therapy (RAM + PAC), compared with paclitaxel monotherapy (PAC), was based on data from the RAINBOW trial. In addition, the company undertook a network meta-analysis (NMA) to compare RAM + PAC with BSC and docetaxel. Cost-ef

Lenalidomide for the Treatment of Low- or Intermediate-1-Risk Myelodysplastic Syndromes Associated with Deletion 5q Cytogenetic Abnormality: An Evidence Review of the NICE Submission from Celgene

The National Institute for Health and Care Excellence (NICE) invited the manufacturer of lenalidomide (Celgene) to submit evidence of the clinical and cost effectiveness of the drug for treating adults with myelodysplastic syndromes (MDS) associated with deletion 5q cytogenetic abnormality, as part of the Institute’s single technology appraisal (STA) process. Kleijnen Systematic Reviews Ltd (KSR), in collaboration with Erasmus University Rotterdam, was commissioned to act as the Evidence Review Group (ERG). This paper describes the company’s submission, the ERG review, and the NICE’s subsequent decisions. The ERG reviewed the evidence for clinical and cost effectiveness of the technology, as submitted by the manufacturer to the NICE. The ERG searched for relevant additional evidence and validated the manufacturer’s decision analytic model to examine the robustness of the cost-effectiveness results. Clinical effectiveness was obtained from a three-arm, European, randomized, phase III trial among red blood cell (RBC) transfusion-dependent patients with low-/intermediate-1-risk del5q31 MDS. The primary endpoint was RBC independence for ≥26 weeks, and was reached by a higher proportion of patients in the lenalidomide 10 and 5 mg groups compared with placebo (56.1 and 42.6 vs 5.9 %, respectively; both p < 0.001). The option of dose adjustments after 16 weeks due to dose-limiting toxicities or lack of response made long-term effectiveness estimates unreliable, e.g. overall survival (OS). The de novo model of the manufacturer included a Markov state-transition cost-utility model implemented in Microsoft Excel. The base-case incremental cost-effectiveness ratio (ICER) of the manufacturer was £56,965. The ERG assessment indicated that the modeling structure represented the course of the disease; however, a few errors were identified and some of the input parameters were challenged. In response to the appraisal documentation, the company revised the economic model, which increased the ICER to £68,125 per quality-adjusted life-year. The NICE Appraisal Committee (AC) did not recommend lenalidomide as a cost-effective treatment. Subsequently, the manufacturer submitted a Patient Access Scheme (PAS) that provided lenalidomide free of charge for patients who remained on treatment after 26 cycles. This PAS improved the ICER to £25,300, although the AC considered the proportion of patients who received treatment beyond 26 cycles, and hence the ICER, to be uncertain. Nevertheless, the AC accepted a commitment from the manufacturer to publish, once available, data on the proport

Sr-Nd isotope geochemistry of the early Precambrian sub-alkaline mafic igneous rocks from the southern Bastar craton, Central India

Sr–Nd isotope data are reported for the early Precambrian sub-alkaline mafic igneous rocks of the southern Bastar craton, central India. These mafic rocks are mostly dykes but there are a few volcanic exposures. Field relationships together with the petrological and geochemical characteristics of these mafic dykes divide them into two groups; Meso-Neoarchaean sub-alkaline mafic dykes (BD1) and Paleoproterozoic (1.88 Ga) sub-alkaline mafic dykes (BD2). The mafic volcanics are Neoarchaean in age and have very close geochemical relationships with the BD1 type. The two groups have distinctly different concentrations of high-field strength (HFSE) and rare earth elements (REE). The BD2 dykes have higher concentrations of HFSE and REE than the BD1 dykes and associated volcanics and both groups have very distinctive petrogenetic histories. These rocks display a limited range of initial 143Nd/144Nd but a wide range of apparent initial 87Sr/86Sr. Initial 143Nd/144Nd values in the BD1 dykes and associated volcanics vary between 0.509149 and 0.509466 and in the BD2 dykes the variation is between 0.510303 and 0.510511. All samples have positive &#949;Nd values the BD1 dykes and associated volcanics have &#949;Nd values between +0.3 and +6.5 and the BD2 dykes between +1.9 to +6.0. Trace element and Nd isotope data do not suggest severe crustal contamination during the emplacement of the studied rocks. The positive &#949;Nd values suggest their derivation from a depleted mantle source. Overlapping positive &#949;Nd values suggest that a similar mantle source tapped by variable melt fractions at different times was responsible for the genesis of BD1 (and associated volcanics) and BD2 mafic dykes. The Rb–Sr system is susceptible to alteration and resetting during post-magmatic alteration and metamorphism. Many of the samples studied have anomalous apparent initial 87Sr/86Sr suggesting post-magmatic changes of the Rb–Sr system which severely restricts the use of Rb–Sr for petrogenetic interpretation

The Context of Sexual Risk Behaviour Among Men Who Have Sex with Men Seeking PrEP, and the Impact of PrEP on Sexual Behaviour.

There are still important gaps in our understanding of how people will incorporate PrEP into their existing HIV prevention strategies. In this paper, we explore how PrEP use impacted existing sexual risk behaviours and risk reduction strategies using qualitative data from the PROUD study. From February 2014 to January 2016, we conducted 41 in-depth interviews with gay, bisexual and other men who have sex with men (GBMSM) enrolled in the PROUD PrEP study at sexual health clinics in England. The interviews were conducted in English and were audio-recorded. The recordings were transcribed, coded and analysed using framework analysis. In the interviews, we explored participants' sexual behaviour before joining the study and among those using or who had used PrEP, changes to sexual behaviour after starting PrEP. Participants described the risk behaviour and management strategies before using PrEP, which included irregular condom use, sero-sorting, and strategic positioning. Participants described their sexual risk taking before initiating PrEP in the context of the sexualised use of drugs, geographical spaces linked with higher risk sexual norms, and digitised sexual networking, as well as problematic psychological factors that exacerbated risk taking. The findings highlight that in the main, individuals who were already having frequent condomless sex, added PrEP to the existing range of risk management strategies, influencing the boundaries of the 'rules' for some but not all. While approximately half the participants reduced other risk reduction strategies after starting PrEP, the other half did not alter their behaviours. PrEP provided an additional HIV prevention option to a cohort of GBMSM at high risk of HIV due to inconsistent use of other prevention options. In summary, PrEP provides a critical and necessary additional HIV prevention option that individuals can add to existing strategies in order to enhance protection, at least from HIV. As a daily pill, PrEP offers protection in the context of the sex cultures associated with sexualised drug use, digitised sexual applications and shifting social norms around sexual fulfilment and risk taking. PrEP can offer short or longer-term options for individuals as their sexual desires change over their life course offering protection from HIV during periods of heightened risk. PrEP should not be perceived or positioned in opposition to the existing HIV prevention toolkit, but rather as additive and as a tool that can and is having a substantial impact on HIV