Diffusion of Technology

BIOE 301 Lecture 20

Review of Last Time: Artificial Heart

 First artificial heart implanted in 1969  No more human trials until the 1980s  AbioCOR – 1 st fully implantable artificial heart

Review of Last Lecture: Study Design

 Type I Error: (False Positive)  Mistakenly conclude there is a difference between the two groups, when in reality there is no difference  p-value = probability of making type I error  Type II Error: (False Negative)  Mistakenly conclude that there is not a difference between the two, when in reality there is a difference  Beta = probability of making type II error

Review of Last Time: Optimal Sample Size

 Sample size calculations  Ensure differences between treatment & control group are real  Choose our sample size:  Acceptable likelihood of Type I or II error  Enough $$ to carry out the trial

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Drug Eluting Stent – Sample Size

Treatment group:  Receive stent Control group:  Get angioplasty Primary Outcome:  1 year restenosis rate Expected Outcomes:   Stent: 10% Angioplasty: 45% Error rates:  p = .05

 Beta = 0.2

55 patients required

Science of Understanding Disease Bioengineering Emerging Health Technologies Abandoned due to:

• poor performance • safety concerns • ethical concerns • legal issues • social issues • economic issues

Preclinical Testing Ethics of research Clinical Trials Cost-Effectiveness Adoption & Diffusion

Introduction

   Sharing of Technology isn’t as simple as merely transplanting Technology from place to place Technology is a system- many components required to make it work, resources vary from country to country Technology needs support of human beings who understand its workings; may vary from country to country

Diffusion is historically slow….

    1497:  Vasco Da Gama lost 100 out of 160 crew members to scurvy sailing around Cape of Good Hope 1601:   British Navy Captain James Lancaster was in command of 4 ships traveling from England to India   Required sailors to take 3 tsp of lemon juice daily on 1 ship The other 3 ships served as the control Results:   110/278 sailors died in control group 0 deaths in the experimental group 1747:  British Navy Physician James Lind repeated study with similar results 1865:  British Navy finally adopted innovation, 264 years after first recorded evidence Berwick, Donald M., Disseminating Innovations in Health Care. JAMA April 16, 2003 – Vol 289, No. 15

Characteristics of people who adopt change

     Innovators  Mavericks, “willing to leave the village”, weird, incautious, socially disconnected, risk takers Early Adopters  Well connected, social opinion leaders, watched by communities Early Majority  Local in perspective, follow the lead of the early adopters Late Majority  Watch for local proof Laggards  Traditional, prefer the “tried and true”, archivists Tipping Point – often between 15% - 20% adoption; spread becomes difficult to stop. Berwick, Donald M., Disseminating Innovations in Health Care. JAMA April 16, 2003 – Vol 289, No. 15

A Case Study

Cholecystectomy: Removal of the Gall Bladder

The Gall Bladder

http://gensurg.co.uk/images/Bil iary%20anatomy%20 %20hsk.jpg

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The Gall Bladder

Function:  Stores bile made by liver  After eating:    Gall bladder contracts Secretes bile into duct which empties into small intestine Aids in digestion Gallstones:  Liquid bile may precipitate into solid stones   Common: 1/5 of North Americans and ¼ Europeans develop gallstones at some point http://www.thaiclinic.com/images/biliary_anatomy.gif

Gallstones

 Symptoms  If gallstones block outflow of bile:  Abdominal discomfort  Pain    Heartburn Indigestion Acute inflammation http://www.qualitysurgical.com/gblad.jpg

Treatment of Gallstones

 Before 1990:       Open surgery to remove the gall bladder Effective Low mortality rate (0.3-1.5%) 7 day hospital stay 30 days lost time from work Most common non-obstetric surgical procedure in many countries

A Case Study: Laparoscopic Cholecystectomy

      Most significant major surgical advance of the 1980s Allows shorter hospitalization Rapid recovery Early return to work Significant financial savings Forerunner of new era of minimally invasive surgery

Laparoscopic Removal of Gall Bladder

        Patient receives general anesthesia Small incision is made at navel and thin tube carrying video camera is inserted Surgeon inflates abdomen with carbon dioxide Two needle-like instruments inserted; serve as tiny hands. Pick up gallbladder & move intestines around.

Several instruments inserted to clip gallbladder artery & bile duct, to safely dissect & remove gallbladder & stones Gallbladder is teased out of tiny navel incision.

Entire procedure normally takes 30 to 60 minutes. Three puncture wounds require no stitches; may leave very slight blemishes. Navel incision is barely visible

Laparoscopic Cholecystectomy

http://www.lapsurgery.com/gallblad.jpg  http://www.laparoscopy.com/pictures/lap_chol.

html

Advantages/Disadvantages

  Benefits:  Ease of recovery     No incision pain as occurs with standard abdominal surgery Up to 90% of patients go home the same day Within several days, normal activities can be resumed No scar on the abdomen Complications:   Complication rate is about the same for this procedure as for standard gallbladder surgery:   Nausea and vomiting may occur after the surgery Injury to the bile ducts, blood vessels, or intestine can occur, requiring corrective surgery 5 to 10% of cases, the gallbladder cannot be safely removed by laparoscopy. Standard open abdominal surgery is then immediately performed.

Did this technology diffuse slowly or rapidly?

An Important Innovator

 Kurt Semm (1927-2003)  Gynecologist    80 medical device inventions     Electronic insufflator Thermocoagulation Loop ligator Laparoscopic suturing Brother and father owned a medical instrument company which rapidly produced instruments for him Allowed more complex procedures to be performed endoscopically   Gynecology General surgery

Laparoscopic Appendectomy

 1985:  Semm’s techniques used to perform the world’s first laparoscopic appendectomy  Said to reduce problem of adhesions formed during opens surgeries

Public Response

    “He’s gone absolutely crazy.” Was asked to undergo a brain scan by his colleagues Lectures were initially greeted with laughter and derision  Technique was initially viewed as too expensive and too dangerous  Semm exaggerated problems of adhesions Surgeons saw no reason to change a well established working method into a complex technical manner

Public Response

   Semm:  “Both surgeons and gynecologists were angry with me. All my initial attempts to publish on laparoscopic appendectomy were refused with the comment that such nonsense does not and will never belong to general surgery.” Gynecologists have “surgeon envy” Semm is trying to enter into general surgery to bolster his “operation ego”

Did this technology diffuse slowly or rapidly?

Diffusion of Lap Choly

http://www.a

cponline.org/j ournals/ecp/ marapr99/diff us.pdf

Diffusion of Lap Choly

http://www.acpon

line.org/journals/e cp/marapr99/diffu s.pdf

Diffusion

  No technique in modern times has become so popular as rapidly as laparoscopic cholecystectomy Semm   Displayed an ability to push his ideas through despite skepticism and suspicion Without Semm, the laparoscopic revolution may have been postponed by many years

Diffusion of Lap Choly

    Diffusion of laparoscopic cholecystectomy in health care is unprecedented Since its introduction in 1989:  the laparoscopic procedure has rapidly become the most widely used treatment for gallstone disease By 1992:  laparoscopic cholecystectomy accounted for 50% of all cholecystectomies in Medicare populations  75% to 80% of all cholecystectomies in younger populations Increased overall rate of cholecystectomy

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Take Home Messages

In most settings:  Rate of cholecystectomy increased dramatically after introduction of the laparoscopic procedure Financial incentives for physicians and hospitals to use the procedure influenced the rate of diffusion Introduction of laparoscopic cholecystectomy:  Associated with a 22% decrease in the operative mortality rate for cholecystectomy

Using Gold to Detect Cancer

How long do you think it will be before we can test this in patients?

Normal Abnormal

Using Gold to Feel Better

  http://www.alchemistsworkshop.com/ http://www.cnn.com/2002/ALLPOLITICS/10/02/ offbeat.blue.candidate/ How long do you think it will be before we can test this in patients?

http://www.amber.org/~laloca/photos/ra ndom/stanjones.jpg

International Diffusion of Technology

     Myth— Technology is largely result of one’s own people --> Technological Nativism No Technologically dynamic nation is autonomous from Technologies of other nations 1500's— China produced most Technology 1500-1700's— Europe leads world in Technological advances Many of these Technologies were the continuation of earlier advances in technology from China and elsewhere

U.S.: Diffusion of Technology

    United States— heavily dependent on Technologies of other countries since its inception Even advances that originated in U.S. are often owed to immigrants Bakelite - ( Leo Baekeland - Belgium) Television Camera- ( Vladimir Zworykin Russia)

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"A country (or an individual firm) that draws on technologies developed elsewhere is spared the expense of ‘reinventing the wheel.’ But making effective use of imported technologies— even if only direct copying is required— often requires a stock of indigenous skill that cannot always be easily found."

Sharing of Technology

 Technologies shared between countries can be used for very different purposes  China— Gun Powder — used medicinally for centuries— passed on to Europe  Europe— within short time using it for cannons and firearms

Technology Transfer

 When Technology is transferred from one country to another, modifications are most likely required for Technology to work; Thus it isn’t the exact same Technology  Japan and Steel Production— Japanese tried to apply Dutch steel production but had to make many modifications.  The special characteristics of Japanese coal and iron ore required special modifications

Rate of Technology Usage

 Equal use of Technologies can have devastating impact  U.S. (pop. 290 million)-- one car/ 1.5 people  China (pop. 1.5 billion)-- one car/ 500 people

Technology brings economic empowerment?

    Not all countries have equal resources (human and material) Even if Technologies can be transferred the results are not always desirable Pakistan— introduction of tractor— replaces worker— 40% unemployment rate Workers migrate to cities— dire poverty results— per acre crop yields hardly increased at all.

Lab to Diffusion

    It often takes a long time for Technology to move from lab. Feasibility to commercial value: Freon refrigerants— 1 year zipper — 27 years Fluorescent lamp --79 years

Summary: The “Not Invented Here” (NIH) Syndrome

 Risky nature of Technological innovation blocks the diffusion of new Technologies  "The status quo is a hell of a lot easier than making changes." Henry Ford

Summary: Factors

      Relative advantages over existing Technology Compatibility w/ existing values of country Ease/difficulty of understanding and applying new Technology Ease of experimentation with new Technology Extent to which positive results appear People with knowledge of Technology are KEY to diffusion of Technology

Read and Reflect

“…Experts are in a position to influence the course of technological change, but at the same time, they face many difficulties in converting their knowledge into power. Having the correct technical answers isn’t enough; wielding power requires the mobilization of a constituency and the ability to create a broad base of support."