Issue 3 / 4 February 2013

INNOVATIONS are considered to be the markers of advancing medical practice.

Many will be familiar with Everett Rogers’ five categories of “adopters” of innovation — the innovators themselves, the early adopters, the early and late majorities and the laggards. However, Rogers, a US sociologist, also considered there were both positive and negative outcomes of innovation.

In his 1962 classic Diffusion of innovations, he listed three categories for consequences: desirable versus undesirable, direct versus indirect, and anticipated versus unanticipated.

In this weeks’ issue of the MJA, several contributions run the gamut of responses to, and consequences of, innovation.

Although vision loss from diabetic retinopathy can be prevented in up to 70% of cases through timely detection and intervention, many patients are not screened. Two articles show the potential role of fundus photography in expanding the screened population.

In a pilot study, researchers found that patients with diabetes were willing to be assessed by pathology collection staff trained in non-mydriatic retinal photography when they attended for routine blood collection. Follow-up after screening, however, was suboptimal.

In the second study, researchers showed that in remote central Australia, single-field fundus photography by a qualified or trainee ophthalmologist was an acceptable screening tool when compared with the clinical gold standard of slit-lamp fundus examination.

An editorial commenting on these innovative approaches says that, regardless of the technology and the model used, the challenge is to deliver the best possible care to every patient. The authors propose that in urban settings a better approach would be for general practitioners to take responsibility for ordering the screening tests and following up the results, while in remote settings, again under direction from the GP, fundus photography could be used to identify those in need of specialist assessment before rather than during remote clinics.

These innovations in service delivery have shown promise in improving patient care, but others that make intuitive sense have had less beneficial consequences.

When plasma D-dimer testing was introduced as part of a diagnostic algorithm for venous thromboembolism (VTE) in WA hospitals, researchers expected a reduction in the number of patients referred for VTE imaging. Instead, in a study conducted over 9 years, there was a marked increase in imaging referrals and an increase in hospitalisations for pulmonary embolism (PE), but no accompanying decrease in deaths from PE.

The authors raise concerns that “overdiagnosis” of VTE may lead to unnecessary complications from anticoagulant therapy.

True innovation involves renewing, changing or creating more effective ways of doing things.

Based on this definition, a recently published study which identified currently funded health practices that were potentially harmful or ineffective is truly innovative. In Matters Arising, one of the authors of that study — Dr Adam Elshaug, NHMRC Sidney Sax Public Health Fellow with joint appointments in the School of Population Health and Clinical Practice at the University of Adelaide and Harvard Medical School in Boston — responds to letters commenting on the study.

Context and clinical judgement are everything, with letter authors writing in support of surgery for obstructive sleep apnoea and the use of prophylactic implantable cardioverter defibrillators; and to advise of research into chlamydia screening of young adults. Elshaug points to the great challenge of accepting new evidence contrary to conventional wisdom, and calls for readers to nominate areas of low-value health care for formal review.

Right on cue, in Letters, the question of whether it is time to review echocardiography monitoring for clozapine-associated cardiac toxicity is raised.

Elshaug says evaluation of established practices is all too rare, yet it’s something that we need to be courageous enough to do.

In the words of Nathaniel Wyeth, US chemist: “… the best solutions are often the ones that are counterintuitive — that challenge conventional thinking — and end in breakthroughs. It is always easier to do things the same old way … why change? To fight this, keep your dissatisfaction index high and break with tradition. Don’t be too quick to accept the way things are being done. Question whether there’s a better way.”

That’s innovation!

Dr Ann Gregory is acting editor of the MJA. Dr Ruth Armstrong is senior deputy editor of the MJA and medical editor of MJA InSight.

This article is reproduced from the MJA with permission.

Posted 4 February 2013

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