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Editorial: Kevin J. Bozic and Joshua J. Jacobs Technology Assessment and Adoption in Orthopaedics: Lessons Learned J Bone Joint Surg Am 2008; 90: 689-690 [Full text] [PDF]

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Innovation Diffusion and the Adoption of New Techniques in Orthopaedics

Aaron G Rosenberg, M.D.   (3 April 2008)

Technology Assessment and Adoption in Orthopaedics

Jay R. Lieberman, M.D.   (2 April 2008)

Technology Assessment and Adoption in Orthopaedics

James H. Herndon, M.D.   (1 April 2008)

Technology Assessment And Adoption in Orthopaedics

Daniel J. Berry, M.D.   (31 March 2008)

Innovation Diffusion and the Adoption of New Techniques in Orthopaedics 3 April 2008
Aaron G Rosenberg, M.D., Surgeon Rush University Medical College, Chicago, IL 60612 Send letter to journal: Re: Innovation Diffusion and the Adoption of New Techniques in Orthopaedics aarongbone{at}aol.com Aaron G Rosenberg, M.D.	To The Editor: The studies by Anglen et al.(1) and Forte et al.(2) demonstrating significant variability in the utilization rates of different devices for internal fixation of inter-trochanteric fractures, conclude what has long been recognized in the study of many health care interventions--high regional variations in levels of device utilization without robust clinical research support for the variability(3). Both studies review various factors that are potentially responsible for this phenomenon, while the accompanying commentary by Bozic and Jacobs provides an excellent overview of technology assessment methods with recommendations for future study(4). Physicians rarely translate research data into clinical practice in a rapid or necessarily appropriate fashion(5). Explanations abound for the gap between what is known and what is done:the difficulty of discerning signal from noise in the clinical setting; the relatively small sample sizes of patients with specific characteristics and a given disease in most studies compared to the expanse of the clinical setting; and the influence of habit and familiarity, rather than the “evidence-base” on physician behavior(5). Unfortunately, technology assessment, and the use of randomized controlled trials (as the exemplar of high quality evidence), assumes a relatively linear but unrealistic process where clinical research passes in a straightforward fashion from creation through dissemination to utilization(6). While providing guidance in areas where adequate trials demonstrate unambiguous differences, such assessments rarely encompass all of the complex features characterizing surgical decision making. It does little to account for, or seek to explain the multiple factors which have been shown to affect the rate at which best practices are adopted. It provides a narrow and reductionistic template by which to evaluate and understand the complexities of clinical behavior An alternate framework that may provide more comprehensive insight into practice variations, is the study of innovation diffusion(7). This paradigm provides a more comprehensive methodology for understanding the principal factors involved in the adoption of specific technical innovations. It has been applied to the study of many innovations from such disparate fields as agriculture and human resource management, to health care and complex financial instruments.It includes technology assessment as only one of the many factors required to understand how individuals, organizations and cultures adopt the “new”(8). In addition to the specific attributes of a given innovation (corresponding to clinical research findings on efficacy, safety, costs, etc), innovation diffusion study evaluates the complex interactions and effects of communications networks, cultural standards,and established practice patterns on adoption rates and patterns. Diffusion theory better helps us understand the complex adaptive process whereby individuals receive, assimilate and adopt evidence in the setting of organizational or environmental factors that can both constrain or facilitate responses to the evidence as well expedite or impede implementation(9). While the health care juggernaut, in both its size and complexity, is perceived as being substantially unlike other fields of human endeavor, using the principles of innovation diffusion holds great promise for helping the medical community better understand the relationship between technology assessment, in both its informal and formal aspects, and the actual delivery of care. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. References: 1. Anglen JO, Weinstein JN; American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. J Bone Joint Surg Am. 2008;90:700-7. 2. Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2008;90:691-9. 3. Birkmeyer JD, Sharp SM, Finlayson SRG, Fisher ES, Wennberg JE. Variation profiles of common surgical procedures. Surgery 1998;124:917-23. 4. Bozic K, Jacobs J;Editorial - Technology Assessment and Adoption in Orthopaedics: Lessons Learned J Bone Joint Surg Am. 2008;90:689-90. 5. Berwick DM; “Disseminating Innovations in Health Care,” JAMA 289(15) (April 16, 2003): 1969-1975. 6. Bowen S, Zwi AB; Pathways to “evidence-informed” policy and practice: A framework for action. (2005) PLoS Med 2(7): e166 7. Rogers EM; The diffusion of innovation. 5th ed. 2003 York: Free Press. 8. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O; Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Quart 2004, 82(4):581-629 9.Lennarson GA; Advances in the study of diffusion of innovation in health care organisations. Millbank Mem Fund Q Health Soc (1977) (Fall): 505–532.
Technology Assessment and Adoption in Orthopaedics 2 April 2008
Jay R. Lieberman, M.D., Director, New England Musculoskeletal Institute. Professor & Chair, Dept. Orthopaedic Surgery University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030 Send letter to journal: Re: Technology Assessment and Adoption in Orthopaedics Ivanov{at}nso.uchc.edu Jay R. Lieberman, M.D.	To The Editor: I read with great interest the studies by Anglen and Weinstein(1) and Forte et al.(2) who demonstrated intriguing variations in practice patterns related to operative management of intertrochanteric hip fractures using data obtained from the American Board of Orthopaedic Surgery and Medicare provider databases respectively. These excellent studies demonstrate an increase in the frequency of use of IM devices even though improved outcomes have not been consistently demonstrated in randomized trials. Furthermore, Forte et al.(2) noted significant regional variations in the use of IM devices. Because of limitations associated with the use of these databases,neither group of authors could specifically delineate the reasons for these changes in practice patterns. However, both suggest that nonpatient factors, such as differences in RVU values and surgeon payments may have contributed to the rapid adoption of this new technology. Clearly, no one knows definitively why young surgeons chose to rapidly adopt the use of IM rods to manage hip fractures but I do not believe that it was reimbursements alone. I would like to use this forum to make a few statements that may stimulate further discussion. First, many surgeons are quick to embrace new technology because there is a general belief that anything new will be associated with better outcomes(3). Second, surgeons are particularly interested in new technology or techniques that are minimally invasive or can be done in a more efficient manner. These types of techniques are also attractive to patients and in an era of declining reimbursements, practice efficiency is important to all of us. Third, surgeons learn about many new surgical techniques and devices in industry sponsored courses where there are subtle suggestions that it is essential that surgeons must be "cutting edge" or they may not be doing what is best for their patients. Finally, the internet and direct to consumer advertising have clearly influenced surgeon behavior. Although hip fracture patients are not asking for new technology, the description of a procedure that is faster with a small incision is compelling to patients and physicians alike. In other areas of orthopaedic surgery we have seen surgeons rapidly adopt new techniques such as minimal incision total joint arthroplasty because of the potential for better outcomes but also the fear of loss of market share. The rapid growth and subsequent decline of the two incision total hip arthroplasty is a cautionary tale that reminds us that new techniques should be carefully studied prior to universal adoption(4). The question remains, " when is it appropriate to incorporate new technology into our own practices and how do we do it?" In their thought provoking editorial, in this same issue, Bozic and Jacobs point out that it is essential that we analyze the nonclinical factors that influence surgeon treatment decisions and the importance of the development of unbiased clinical practice guidelines based on high quality evidence(3,5). We now use the term "evidence based medicine" but we are so accustomed to making decisions based on dogma and experience that we have not made "evidence based medicine" an essential aspect of everyday clinical practice. I have been actively involved in resident education for the past 17 years and we have not focused enough on training residents with respect to determining how to evaluate new technology and when to incorporate it into one’s practice. The next generation of orthopaedic surgeons should be taught how to not only carefully scrutinize the literature but also demand from manufacturers and surgeon innovators that high quality randomized trials be performed as part of both pre-market approval and post-market surveillance so choices can be made with the appropriate information available. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated . References: 1. Anglen JO, Weinstein JN; American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. J Bone Joint Surg Am. 2008;90:700 -7. 2. Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF. Geographic variation in device use for intertrochanteric hip fractures. J Bone Surg Am. 2008;90:691-9. 3. Lieberman JR, Wenger N; New Technology and the Orthopaedic Surgeon: Are you Protecting your Patients? Clin Orthop Relat Res. 2004;429:338-341. 4. Archibeck MJ, White RE Jr., Learning curve for the two-incision total hip replacement. Clin Orthop Relat Res. 2004 Dec;(429): 232-8. 5. Bozic KJ, Jacobs JJ, Technology Assessment and Adoption in Orthopaedics: Lessons Learned. Editorial J Bone Joint Surg Am.2008;90:689- 90.
Technology Assessment and Adoption in Orthopaedics 1 April 2008
James H. Herndon, M.D., Residency Program Director, Orthopaedic Department Massachusetts General Hospital, Boston, MA Send letter to journal: Re: Technology Assessment and Adoption in Orthopaedics jherndon{at}partners.org James H. Herndon, M.D.	To The Editor: I read the articles of Anglen and Weinstein(1), Forte, et al.(2), and the editorial by Bozic and Jacobs(3)with fascination. The issue…introduction of a new technology into the daily armamentarium of orthopaedic surgeons…how it’s done, motivating factors, geographic variation in use, risks to our patients’ safety and concerns for the lack of scientific evidence-based data to support its use and the lack of any real meaningful post-market surveillance…are not new ideas, although all are challenging to our profession. What is important, in addition to asking about reasons and explanations concerning the above issues, is that each of the two articles, with excellent data, for the first time, draws our attention to a specific example of a new technology that is being widely used…although variable in regions…as Anglen and Weinstein state “despite a lack of evidence in the literature"(1). I remember when the first IM nail for intertrochanteric fractures became available and one our faculty members was part of a national study to determine its’ safety and efficacy. There was an obvious learning curve and there were technical problems; but there was less blood loss and muscle trauma, and the implant appeared to many to be “biomechanically stronger” than a compression screw and side plate, suggesting that earlier full weight bearing ambulation might be possible. Improvements and modifications of these early IM devices continued until the current popular model. I have learned that the implant is easier to use and importantly, in some surgeons’ hands, it can be inserted faster than using a compression screw. I spoke to some of our residents about their instruction by our trauma team regarding the indications and use of both devices. They stated they are taught to use both…the compression screw and plate for common types of stable intertrochanteric hip fractures and the IM device for unstable intertrochanteric fractures and subtrochanteric fractures. Some who moonlight informed me that the IM device is used more often in the community than is the compression screw. Bozic and Jacobs(3) list the important issues regarding introduction of new technologies and the “nonclincial factors influencing use decisions.” I agree with all of them. But I must admit that I am concerned that preference for the IM device over the compression screw may be related to reimbursement. The IM devise takes less time…therefore the surgeon can do more cases. Medicare pays differently for each and gives different RVU rates for each…in Boston, CPT code #27244 (compression screw) is awarded 30.32 RVUs and the surgeon is paid 80% of $1,235; CPT code #27245 (IM device) is awarded 37.17 RVUs and the surgeon is paid 80% of $1,514. With our reimbursement system a mess, payment has become a major incentive for physicians’ and surgeons’ behavior. Why is anyone surprised at the increasing use of IM devices for even stable intertrochanteric fractures? A final comment relates to registries and the lack of an evaluation system for new technologies to help surgeons evaluate their choices for their patients. More market surveillance is needed for patient safety…the fact that the US does not have orthopaedic registries whereas many other countries do is hard to accept. The American College of Surgeons began the process of providing technology assessment for surgeons in practice. The AAOS has been discussing the issue for years, the members have requested it, but it is still not available to practicing orthopaedic surgeons. Until we have improved clinical trials to document the safety, efficacy and outcomes of a new technology before it is released to the general market, I believe our professional organizations must provide this valuable information to all orthopaedic surgeons. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (MGH Department Funds for Research, Education, and Consulting) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References: 1. Anglen JO, Weinstein JN, on behalf of the American board of Orthopaedic Surgery Research Committee. J Bone Joint Surg Am. 2008;90:700- 7. 2. Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2008;90:691-9. 3. Bozic KJ, Jacobs JJ. Editorial. Technology assessment and adoption in orthopaedics: Lessons learned. J Bone Joint Surg Am. 2008;90:689-690.
Technology Assessment And Adoption in Orthopaedics 31 March 2008
Daniel J. Berry, M.D., Chair, Department of Orthopaedic Surgery Mayo Clinic, 200 First St., SW, Rochester, MN 55905 Send letter to journal: Re: Technology Assessment And Adoption in Orthopaedics daniel.berry{at}mayo.edu Daniel J. Berry, M.D.	To The Editor: Articles authored by Anglen et al.(1) and Forte et al.(2) in this month’s issue of the Journal present important and provocative information about the increasing use of intramedullary nails versus sliding compression hip screws with side plates for the treatment of intertrochanteric hip fractures in the United States. Taken together, the articles clearly demonstrate a changing national practice pattern,a trend toward intramedullary nail use among orthopedic surgeons in their first two years of practice from 1999 to 2006, as well as notable state to state geographic variation in utilization of these technologies from 2000 to 2002. Both papers note these changes have taken place despite lack of consistent evidence to date of the superiority of intramedullary nails compared to compression hip screws with side plates (except for several specific less common fracture patterns). One may speculate that a number of factors could drive surgeons to use intramedullary nails more frequently: convenience and consistency (an intramedullary nail probably is suitable for virtually all intertrochanteric fracture patterns while a compression hip screw with side plate should be performed selectively); operative simplicity (as surgeons have grown more comfortable with intramedullary nailing have they concluded it is an easier and/or faster procedure?); fashion (new technology in surgery as in many aspects of life appeals to many people); economics (physician reimbursement is slightly better for intramedullary fixation compared to a compression hip screw with side plate); and marketing (the price of intramedullary nails is much greater than compression hip screws with side plates so manufacturers probably have an incentive to selectively market intramedullary devices). In an ideal world, a new technology would be introduced only after it was shown, in carefully conducted studies with Level I evidence, to produce better clinical results, to be safer with fewer serious complications, and more cost effective than its predecessor. Unfortunately, this ideal method of technology introduction often is impractical because there are many impediments to performing timely, high quality, large volume studies—as noted in the thoughtful accompanying editorial by Bozic and Jacobs(3). Furthermore the results of such studies may become obsolete, when they cannot stay abreast of and account for evolving technical expertise as surgeons become familiar with a new technology. The orthopedic community should ask why the noted change in practice pattern for intertrochanteric hip fractures has occurred. We also should consider whether further ongoing analysis of this particular change in practice pattern can shed light on the broader, and vitally important question, of what drives adoption of new technologies. A deeper understanding of this "process" may help our profession find methods to adopt new technology in a timely and responsible manner that optimizes benefit and value, and minimizes risk to our patients. The author did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Depuy). Also, a commercial entity (Depuy) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References: 1. Anglen JO, Weinstein JN, on behalf of the American Board of Orthopaedic Surgery Research Committee. J Bone Joint Surg Am. 2008;90:700-7. 2. Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2008;90:691-9. 3. Bozic KJ, Jacobs JJ. Editorial. Technology assessment and adoption in orthopaedics: Lessons learned. J Bone Joint Surg Am. 2008;90:689-690.

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