How Does Innovation Spread?

In a word, slowly. Our colleagues in the field of psychology tell us that human beings are incredibly resistant to change. But what about in the healthcare industry where innovation is expected and even demanded of physicians and hospitals? Thousands of clinical studies are published every year and based just on the sheer volume of clinical literature, one might assume that medicine is universally dynamic, infused with an ethical mandate to roll-out innovations as rapidly as possible. But even if we assume that a true innovation in clinical care has been identified, historical experiences suggest that the healthcare industry is as resistant to change - if not more so - than other industries.

Caused by blood clots in the brain's blood vessels, ischemic stroke is a leading cause of death and disability in the United States. Prior to the mid-1990s, there were no effective treatments for ischemic stroke. Although ischemic stroke patients arriving at the hospital would receive supportive medical care, there were no known pharmaceutical or surgical interventions proven to lyse or remove the blood clot. However, in 1996, on the strength of a study published in the New England Journal of Medicine, the FDA approved the intravenous delivery of the clot-busting tissue plasminogen activator (tPA) as the first treatment for acute ischemic stroke.

The first true therapy for ischemic stroke had been approved, the optimists sat back and waited for a dramatic spike in the use of tPA and a concomitant improvement in clinical outcomes.

However, despite tPA's FDA approval and a rash of subsequent studies confirming the drug's clinical efficacy for treating ischemic stroke, the use of tPA remained surprisingly low. Even today, only 1-5 percent of ischemic stroke patients nationally receive tPA. The reasons are many. First, to be eligible for tPA, patients must present to the hospital within three hours of stroke onset. Second, there are a host of physiological contraindications to tPA that disqualify many patients. Yet, even among patients who are eligible for tPA, the national treatment rates range from 15-20 percent.

Why aren't more eligible ischemic stroke patients receiving tPA? Innovation spreads slowly.

Transparency

NetDoc recently combined data on hospital quality outcomes - as reported by hospitals to the Department of Health & Human Services - with Google Maps to provide a diagnostic snapshot of hospital quality. In grading each individual hospital, the tool combines data on heart attacks, heart failure, pneumonia, surgical infection prevention to create an overall "clinical quality metric" for each hospital.

This website is just one more indicator of the slow shift towards transparency in the U.S. healthcare system. Information is the mediator of free market competition and an increase in transparency in hospital performance will play an important role in improving overall quality of care. Patients will be able to make more informed decisions about providers and hospitals will emulate positive deviants in the market to improve outcomes and stay competitive.

Measuring Things

I recently read Better: A Surgeon's Notes on Performance, a wonderful collection of essays penned by Atul Gawande, a general surgeon and frequent contributor to The New Yorker. I was struck by one passage in particular:

"Regardless of what one ultimately does in medicine - or outside of medicine for that matter - one should be a scientist in this world . In the simplest terms, this means one should count something. The clinician might count the number of patients who develop a particular complication from treatment - or just how many are actually seen on time and how many are made to wait."

How can a hospital improve clinical outcomes without first understanding how its outcomes compare to outcomes at peer institutions? The larger argument is that in any given endeavor - medicine, baseball, farming - there are positive deviants that, by definition, outperform the average. Just as some baseball players consistently bat above the league average, some physicians and some hospitals consistently create superior clinical outcomes. In the case of hospitals, how much could they improve the quality of care delivered if they could identify and emulate positive clinical deviants among other hospitals? Why is the Mayo Clinic more successful at treating pituitary tumors than 95 percent of other U.S. hospitals? What are they doing right?

At the Organization for Economic Cooperation and Development (OECD), a sort of best-practices organization for the world's developed nations, researchers are developing a comprehensive set of healthcare quality indicators that will eventually allow policy makers to compare clinical performance across healthcare systems. The development of metrics for the assessment of clinical quality - breast cancer survival rates, stroke 30-day mortality rates and colorectal cancer screening rates - will help answer important questions. What does the French healthcare system do better than the Spanish healthcare system? Why does it do it better?

I think they're great questions and will hold important lessons for individual institutions and systems.