The Diffusion of Medical Innovations: An Applied Network Analysis

286 Pages·1988·4.482 MB·English

by  Mary L. Fennell, Richard B. Warnecke (auth.)

The Diffusion of
Medical Innovations
An Applied Network Analysis
ENVIRONMENT, DEVELOPMENT, AND
PUBLIC POLICY
A series of volumes under the general editorship of
Lawrence Susskind, Massachusetts Institute of Technology, Cambridge, Massachusetts
PUBLIC POLICY AND SOCIAL SERVICES
Series Editor:
Gary Marx, Massachusetts Institute of Technology, Cambridge, Massachusetts
THE DIFFUSION OF MEDICAL INNOVATIONS: An Applied
Network Analysis
Mary L. Fennell and Richard B. Warnecke
FATAL REMEDIES: The Ironies of Social Intervention
Sam D. Sieber
INNOVATION UP CLOSE: How School Improvement Works
A. Michael Huberman and Matthew B. Miles
OSHA AND THE POLITICS OF HEALTH REGULATION
David P. McCaffrey
RACIAL AND CULTURAL MINORITIES: An Analysis of Prejudice
and Discrimination (Fifth Edition)
George E. Simpson and J. Milton Yinger
STABILITY AND CHANGE: Innovation in an Educational Context
Sheila Rosenblum and Karen Seashore Louis
Other subseries:
ENVIRONMENTAL POLICY AND PLANNING
Series Editor:
Lawrence Susskind, Massachusetts Institute of Technology, Cambridge, Massachusetts
CITIES AND DEVELOPMENT
Series Editor:
Lloyd Rodwin, Massachusetts Institute of Technology, Cambridge, Massachusetts
The Diffusion of
Medical Innovations
An Applied Network Analysis
Mary L. Fennell
The Pennsylvania State Universily
Universily Park, Pennsylvania
and
Richard B. Warnecke
Universily of Illinois at Chicago
Chicago, Illinois
Plenum Press • New York and London
Library of Congress Cataloging in Publication Data
Fennell, Mary L.
The diffusion of medical innovations: an applied network analysis I Mary L. Fennell
and Richard B. Warnecke.
p. cm.-(Environment, development, and public policy. Public policy and
social services.)
Bibliography: p.
Includes index.
ISBN-13: 978-I -4684-5438-3 e-ISBN-13: 978-1-4684-5436-9
om: 10.1007/978-1-4684-5436-9
1. Cancer-Treatment-United States-Technological innovations. 2. Diffusion of
innovations-United States. 3. Cancer-Hospitals-United States. 4. Network analysis
(Planning) I. Warnecke, Richard B. II. Title. III. Series. [DNLM: 1. Communication. 2.
Interinstitutional Relations. 3. Research. W 20.5 F335d]
RC270.8.F46 1988
616.99'406-dc19 88·2475
CIP
© 1988 Plenum Press, New York
Softcover reprint of the hardcover 1st edition 1988
A Division of Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical. photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
For Dennis and Barbara
Preface
This book has several objectives. Most basically it presents an approach to assessing
interorganizational innovation diffusion. To do this we have tried to link contempo
rary organizational theory with more person-centered diffusion theory. We have
also combined contingency theory with the resource dependence perspective to
explain why organizations might choose to initially consider an innovation, re
define it to suit their particular environmental context, and then implement it.
Another objective has been to examine how environmental constraints can
limit the ways in which diffusion channels form, and can determine when diffusion
can be truly organizational and when it will depend upon individuals. In doing so,
we have tried to indicate how organizational structures emerge to manage re
sources in ways that are consistent with those environmental constraints. We have
borrowed the notion of boundary management from resource dependence, and we
have used it to examine how organizations use various boundary management
strategies to preserve their autonomy in exchange relationships with other organi
zations. We have done this both at the network level and at the level of individual
organizations.
When we conducted this study (in the late 1970s and early 1980s), the "net
work" strategy had just been adopted by the National Cancer Institute as a method
for disseminating state-of-the-art cancer treatment strategies. The data we present
and the observations we have made provide a view of a strategy just beginning to
unfold. This early vantage point has given us what we believe is a unique view of a
major organizational effort sponsored by the NCI to disseminate scientific informa
tion from research centers to community practitioners and community hospitals. By
viewing the system at this early timepoint we have been able to show how perfor
mance gaps were identified by various parties in this process, and how they influ
enced agenda setting at the local, regional, and national levels as part of the "War
on Cancer." We were also able to examine closely how early network strategies
were implemented in various types of environments.
Because these were very large organizational systems, and the networking ap
proach was at an experimental stage, we adopted a combined qualitative/quanti
tative methodology to chronicle the development of these cancer networks. Those
social scientists who see the word network will probably immediately see blockmodel-
vii
viii PREFACE
ing and other quantitative techniques that have developed in social network analysis.
These data do not lend themselves to this type of analysis, and with the exception of
Chapter 5, readers will find very little of it here. However, we hope you will bear with
us, because we believe the reader will find considerable empirical evidence in sup
port of the diffusion model we present.
Another type of caution is also pertinent. Because the diffusion strategy de
scribed here was new and had not been tested elsewhere, it would be easy to
conclude that the system was largely ineffective. This would be an error. Although
there were factors in this program that inhibited the NCI in attaining some of its
stated objectives, the results of this initial effort had far-reaching consequences for
the national cancer program and for all of the institutions that participated.
The results of this first effort greatly influenced subsequent diffusion efforts.
Many different forms of diffusion networks followed this first attempt, each with a
different focus or set of objectives. But all of them were designed to somehow
strengthen the ties linking community hospitals to the objectives of the NCI. In
each instance the objective was to increase the access of cancer patients to newly
developed treatment strategies, and to provide newly trained oncologists who
chose to practice in community hospitals with better access to state-of-the-art treat
ment methods. In most instances the source of the state of the art was a university
research center, or in some cases the NCI. However, as these programs developed,
the community physician increasingly became a partner in both the development of
that knowledge and its implementation.
Thus, this book is really a first look at an ongoing program of diffusion. We
hope that it will stimulate others to apply the concepts discussed here in the
examination of other attempts at diffusion of state-of-the-art treatment or patient
care strategies for other diseases and in other contexts. This was another purpose in
writing the book: We have tried to develop a methodology and conceptual frame
work to be used by other health services researchers in conducting such studies.
Overall, then, we view this book as an attempt to examine organizational
change in the delivery of cancer treatment resulting from the introduction of new
treatment strategies and patient management techniques. If we have been suc
cessful, it might provide guidance about when such strategies can be effectively
applied and when they cannot. It might also be useful in identifying the limits of
such strategies and what impact the diffusion efforts themselves are likely to have
on the form of the technology that is ultimately diffused. We have taken the
position that the social and organizational context of diffusion itself forces changes
in the form of the innovation. This is particularly likely when the innovation is a set
of concepts about treatment, rather than a particular treatment technology based solely
on particular hardware. How this change occurs and what might be done to pro
mote consistency in the diffusion of new treatment strategies are important issues,
but difficult to discuss given the data we have. Nevertheless, we have made an
attempt.
Acknowledgments
In a project of this size and length, many individuals make contributions. The
actual project was carried out under a contract with the NCI (NOI-CN-95446-46).
However, this book represents an interpretation of the data from that contract that
is our responsibility and does not reflect the opinions or policies of the NCI. More-
PREFACE ix
over, the reader should be aware that these data were collected from 1978 through
1982, and they therefore do not reflect current activities at any of the programs or
institutions discussed.
In addition to the Ncr contract support, Dr. Fennell was provided support in
the form of release-time from teaching, computer facilities, and staff support from
the Department of Sociology at the University of Illinois at Chicago. Dr. Warnecke's
time was also supported under two grants from the Ncr, Cancer Control Science
Program (CA34886) and Community Interventions for Cancer Prevention (P01-
CA42760).
Rosemary Yancik was the project officer on the initial contract from the Ncr
and provided considerable assistance in completing the initial research. She also
critically read drafts of the materials developed under that contract and provided
good feedback. However, the content of this book in no way reflects the opinions of
Dr. Yancik.
We are also indebted to the principal investigators of the individual network
projects who generously and graciously made available the materials and other
information necessary to conduct this research. Again, the interpretation of these
materials is ours, but the original resources came from these programs. Specifically,
we would like to thank James Y. Suen (University of Arkansas for Medical Sci
ences), James H. Brandenburg (University of Wisconsin), Donald Shedd (Roswell
Park Memorial Institute), John M. Lore (State University of New York at Buffalo),
Sol Silverman (University of California at San Francisco), Luther Brady
(Hahnemann Medical Center), Frank Hendrickson (Rush University), George Sis
son (Northwestern University), and Emmanual M. Skolnick (University of Illinois).
A special note of thanks is due Jerellyn Logemann (Northwestern University),
who was a coinvestigator on the original evaluation contract and who had also been
a major participant in the rehabilitation program of the network. Her observations
and insights were most helpful in enhancing our understanding of these networks.
As our project coordinator and Number One Research Assistant, Penny L.
Havlicek performed yeoman's work throughout the research project and completed
a most impressive doctoral thesis using the project data. Her efforts and input were
not restricted to Chapter 6.
Of our many colleagues at the University of Illinois at Chicago, Chris Ross was
extremely helpful in the network analysis of our survey data. He is a patient teacher
as well as a good friend.
Dorothy Young assisted us throughout the project, typing early manuscripts
and all tables for the final manuscript. The library of Bowdoin College in
Brunswick, Maine, was most generous in providing library resources and a study
carrel to Dr. Fennell for two summers. Major portions of this manuscript were
drafted in those cool, restful environs. The final word processing of the manuscript
could not have been accomplished without Dennis Hogan's IBM-XT and his Laser
Jet printer.
Finally, our respective families provided support and listened to endless dis
cussions about this book. Special thanks to Dennis Hogan and Barbara Warnecke
for their support and encouragement throughout the project.
Mary L. Fennell
Richard B. Warnecke
Contents
CHAPTER 1
MEDICAL INNOVATIONS AND INTERORGANIZATIONAL DIFFUSION
Introduction ......................................................... 1
Historical Background of Networks in the Health Sector ................. 5
Background of the Head and Neck Cancer Demonstration Networks ...... 11
Organizational Networks and the Diffusion of Innovation. . . . . . . . . . . . . . . . 16
Focus of This Study .................................................. 23
CHAPTER 2
DATA AND METHODS
Introduction: Process Evaluation and Retrospective Case Studies ......... 27
Primary Sources ...................................................... 28
Secondary Sources ................................................... 31
The Process of Synthesis .............................................. 35
Thumbnail Sketches .................................................. 36
CHAPTER 3
NETWORK ENVIRONMENT AND RESPONSE TO UNCERTAINTY:
PERFORMANCE GAPS AND DEFINITION OF THE INNOVATION
Introduction ......................................................... 63
Diffusion and Uncertainty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Types and Characteristics of Innovations ............................... 67
The Innovation in Head and Neck Cancer Treatment.................... 70
Performance Gaps, Agenda Setting, and the Network Programs .......... 72
xi
xii CONTENTS
CHAPTER 4
CONSIDERING THE ENVIRONMENT: ENVIRONMENTAL CONTEXT
AND NETWORK FORM
Introduction ......................................................... 79
Boundary Spanners and Interorganizational Linkage . . . . . . . . . . . . . . . . . . . . . 80
The Innovation Diffusion Model ....................................... 82
Considering the Environment ......................................... 86
Relating Environmental Characteristics to Diffusion Channel Form .... . . . . 92
Summary ............................................................ 112
CHAPTER 5
NETWORK FORM, NETWORK STRUCTURE, AND
BOUNDARY MANAGEMENT
Introduction ......................................................... 115
Network Form and Boundary Management ............................. 116
Boundary Management and Network Structure ......................... 121
General Purpose Linkages: Analysis of the Relationship between Context
and Linkage Structure .............................................. 145
Summary ............................................................ 155
CHAPTER 6
VARIATION ACROSS HOSPITALS IN NETWORK PROGRAM
PARTICIPATION
PENNY L. HAVLICEK
Introduction 157
Organizational Power ................................................ . 158
Interest Structure .................................................... . 159
Measuring Power, Interest Structure, and Participation ................. . 161
Power and Participation ............................................. . 165
Interest Structure and Participation ................................... . 167
Summary and Conclusions ........................................... . 169
CHAPTER 7
DEFINITION AND DIFFUSION OF THE INNOVATION
Introduction ......................................................... 171
Definition of the Innovation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . 172
Reinvention: Alternative Definitions of the Innovation ................... 173
Implementation Strategies ............................................. 177