Abstract
The current high and escalating costs of medical care in the U.S. has prompted a renewed interest in how new treatments become part of established medical practice. Moreover, recent findings have raised serious questions concerning the efficacy of several commonly accepted treatments.1 As the related disciplines of medical technology assessment and adoption are fairly new, there is much controversy concerning underlying mechanisms and approaches to studying these phenomena.2 Essentially, three perspectives on treatment assessment and adoption have started to emerge.
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Notes and References
For example, coronary bypass had become well-established before being properly assessed. Several recent studies have suggested that bypass may have been significantly over provided (e.g. Brook, Robert H. and Mary E. Vaiana, Appropriateness of Care: A Chart Book, Washington, D.C., George Washington University, National Health Policy Forum, 1989)
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The ambiguity of criteria used to locate a treatment innovation along the experiment-therapy continuum is acknowledged by those holding this viewpoint. The search continues for indicators to help determine degrees of treatment efficacy and therapeutic value given severity of different illnesses and urgency of treatment (see Fox and Swazey, Ibid note 3, pp. 60–83
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Economic historians Brian Arthur and Paul David have discussed the surprising way in which minor historical events can set a technology on a specific path that is not guaranteed to be efficient, nor is easily altered. An example that David cites is the QWERTY keyboard. Although the QWERTY design is less efficient than competing keyboard arrangements, too much is invested in the QWERTY for manufacturers or users to easily switch to newer designs. Moreover, positive feedback, where the more a technology is adopted the more it is improved, serve to reinforce a given technological path (See Paul David “Clio and the Economics of QWERTY”, Economic History, V.75, 1985, pp. 227–332)
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This position is consistent with the position taken by Van de Ven and Garud, who suggest that to understand the evolution of new industries, we must examine multiple arenas of action that include the instrumental, resource procurement, and the institutional. See Van de Ven and Garud, “A framework, for understanding the emergence of new industries”, in Rosenbloom, R.S. and Burgelman, R. A. Research on technological innovation, management and policy, Vol. 4, pp. 195–225, 1989
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Other concepts that are relevant to an understanding of the concept of technological trajectory include: technological style (see Hughes, T.P. Networks of Power: Electrification in Western Society, 1880–1930 Baltimore, Johns Hopkins University Press, 1983)
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technological orientation complex (see Weingart, P. “The structure of technological change: Reflections on a sociological analysis of technology” in Laudan, R. (ed.) The Nature of Technological Knowledge: Are Models of Scientific Change Relevant? Dordrecht, Reidel, 1984, pp. 115–142)
technological regime (Nelson, R. and S. Winter “In Search of a Useful Theory of Innovation” Research Policy 6, 1977, pp.36–76). Rather than define each of the terms, we direct the reader to The Social Construction of Technological Systems by Bijker, Hughes and Pinch (1987) as an efficient way to understand these concepts in technology studies.
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Chronic renal failure afflicts well over 100 thousand Americans and perhaps millions worldside, annual treatment costs have reached nearly seven billion dollars in the US alone (see U.S. Renal Data System 1991 and 1993 Annual Reports Bethesda, MD: The National Institutes of Health, National Institute of Diabetes and Digestive and Renal failures). The cost of the end-stage renal failure program (the federal program that pays for dialysis and transplantation) has risen at an annualized rate of roughly 20 percent per year since the program’s inception in 1972 (Fox and Swazey, 1978: 349; Ibid note 3).
Giovannetti, Sergio. “Dietary Treatment of Chronic Renal Failure: Why Is It Not Used More Frequently?” Nephron. V40, 1985, pp. 1–12
Giovannetti, Ibid note 21
Mitch, William and MacKenzie Walser “Nutritional Therapy of the Uremic Patient” in Brenner, B. and Rector, F. (eds.) The Kidney. Philadelphia: W.B. Saunders, 1991, pp. 2186–2222
Brenner, B. and Rector, F. Ibid note 22.
Fox and Swazey, Ibid note 3
see Thomas, Lewis. The Lives of a Cell New York, Viking Press, 1974 especially pp. 31–36.
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Mitch, William and MacKenzie Walser “Nutritional Therapy of the Uremic Patient” in Brenner, B. and Rector, F. (eds.) The Kidney. Philadelphia: W.B. Saunders, 1991, pp. 2186–2222.
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Mitch & Walser, Ibid note 22
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Rettig, Richard A. (1976) “The Policy of Debate on Patient Care Financing for Victims of End-Stage Renal Disease” Law & Contemporary Problems. V40/4, Autumn, 196–230.
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Rettig, Ibid note 37, p. 210.
Freidson, 1986, Ibid note 7, p.2.
Fox and Swazey, Ibid note 3
Thomas, Ibid note 25; Bricker, Neal, M.D. Personal Communication December, 1991.
Medical World News (1966) “Renal Group Eases Policy on Dialysis” April 8, p83; Rettig, Richard A. “Valuing Lives: The Policy Debate on Patient Care Financing for Victims of End-stage Renal Disease” Rand Paper Series, 1976.
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Fox and Swazey, Ibid note 3.
Rettig, Ibid note 37
Fox and Swazey, Ibid note 3; pp. 348–349
Rettig, Ibid note 43.
Fox and Swazey, Ibid note 3; p. 349.
Kolata, G. 1980. “NMC thrives selling dialysis”. Science. 208/25 April, 1980, pp. 379–381.
p. 379.
Kolata Ibid note 48
Relman, A. and D. Rennie “Treatment of End-stage Renal Disease: Free but not equal” The New England Journal of Medicine 303/17, 1980, pp. 996–998.
Kolata, Ibid note 48.
Fox and Swazey, Ibid note 3: p. 363.
Kolata, Ibid note 48
Rettig, Ibid note 36.
Kolata, Ibid note 48.
Today the discrepancy may be even more pronounced: $6,000–8,000 versus $31,000 for in-clinic dialysis (USRDS, 1992). Starr, Paul (1982) The Social Transformation of American Medicine. New York: Basic Books, Inc., see pp. 442–443.
Bovbjerg, Randall R., Philip J. Held and Louis H. Diamond (1987) “Provider-Patient Relations and Treatment Choice in the Era of Fiscal Incentives: The Case of the End-stage Renal Disease Program” The Milbank Quarterly. V65, No 2, 177–202.
Starr, Paul (1982) The Social Transformation of American Medicine. New York: Basic Books, Inc., see pp. 442–443 The outcome data on home dialysis was and has continued to be comparable to those of in-clinic dialysis (USRDS, 1994, Ibid note 20).
Daniels, R. 1991. “Legislation in the American dialysis industry: Some considerations about monopoly power in renal care.” American Journal of Economics and Sociology. 15/2: pp. 223–242; USRDS Ibid note 19
Barnett, Andy H., T. Randolph Beard and David Kaserman “Inefficient Pricing Can Kill: The Case of Dialysis Industry Regulation” Southern Economic Journal V60/2 October 1993, pp. 393–404. NMC has continued to grow at a healthy clip. Annual revenues were $316 million in 1985, and they are estimated today to be $1 billion. (Standard and Poor Register of Corporations, Directors and Executives. New York: Standard and Poor, 1993: V1).
Kolata, Ibid note 48, p. 381.
Bovbjerg et al., Ibid note 55.
Urban Institute Survey of Dialysis Institutions (SODI) (Random National Survey of Dialysis Units) Washington, D.C., Urban Institute, 1985.
Greenspan, R.E. (1981) “The High Price of Federally Regulated Hemodialysis” Journal of the American Medical Association. V246, No. 17, October, pp.1901–1911.
Barnett et al., Ibid note 57; Ben Burton, long time head of the of the NIH contract program concerned with chronic renal failure also suggested the importance of economics in guiding the specialty’s technological emphasis.
Eggers, P.W. “Health Care Policies/Economics of the Geriatric Renal Population” American Journal of Renal failure 15/5, 1990, pp.375–383.
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USRDS, 1991, Ibid note 20, p. 10.
Altman, Ibid note 64.
Fox and Swazey, Ibid note 3.
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Starzl, Ibid note 69.
Starzl, Ibid note 69.
Starzl, Ibid note 69. The new immunosuppressant, FK506 (prograf) was approved by FDA in 1994 and has shown some promise in reducing the morbidity and rejection rates that have plagued transplanation.
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Rettig, Ibid note 73., p. 195.
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Fox and Swazey, 1992, Ibid note 14.
That figure can be found in respected publications such The New York Times (see Kolata, Gina. 1990. “American Transplant Pioneers Win Nobel Prize in Medicine” The New York Times. October 9, C3) as well as scientific publications. For instance the 90 percent transplantation success figure was commonly quoted in the recent book-length study by the National Academy of Science’s Institute of Medicine on Renal failure
(see Rettig, Richard and Levinsky, Norm. 1991. The Federal Government and End-stage Renal Disease. Washington, Institute of Medicine).
Kutner, Ibid note 78
Daniels, Ibid note 57.
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As DPR is an early stage intervention treatment, it is best applied to chronic kidney patients early in their disease much the way carbohydrate restricted diet is provided for new diabetes patients. Complete care would likely include a DPR regimen administered directly by a nephrologist and a renal dietitian, and would include regular blood tests for creatinine and glomerular filtration rate to determine kidney function over time. Renal dietitians would train patients in locating and preparing low protein and low phosphorous meals. Careful monitoring of the patient continues after entry onto dialysis.
A lively discussion is continuing regarding the interpretation of the MDRD and the recommendations that can be made based on the findings Mitch, William. Personal communication, 1996).
Walser has produced data that show patients who have been on a DPR regimen enter dialysis healthier than a control group (eg. Walser, MacKenzie. 1993. ‘‘Does prolonged protein restriction preceding dialysis lead to protein malnutrition at the onset of dialysis” Kidney International V44/5, November: 1139–1144).
Fox and Swazey, Ibid note 3.
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Giovannetti, Ibid note 99.
That “shortcoming” of DPR was addressed by the recently completed Modification of Diet in Renal Disease (MDRD)—a ten year prospectively conducted study, see Klahr et al., Ibid note 105
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Ahlstrom, D., Garud, R. (1996). Forgotten Paths in Medicine: The Case of the Low Protein Diet in Chronic Renal Failure. In: Geisler, E., Heller, O. (eds) Managing Technology in Healthcare. Management of Medical Technology, vol 1. Springer, Boston, MA. https://doi.org/10.1007/978-1-4613-1415-8_8
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