1. Diffusion of Technology
BIOE 301
Lecture 20

2. Review of Last Time: Artificial Heart
First artificial heart implanted in 1969
No more human trials until the 1980s
AbioCOR – 1st fully implantable artificial heart

3. 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

4. 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

5. 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

6. Science of Understanding Disease
Emerging
Health Technologies
Bioengineering
Preclinical Testing
Ethics of research
Clinical Trials
Adoption & Diffusion
Abandoned due to:
poor performance
safety concerns
ethical concerns
legal issues
social issues
economic issues
Cost-Effectiveness

7. 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

8. 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

9. 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

10. Cholecystectomy: Removal of the Gall Bladder
A Case Study
Cholecystectomy: Removal of the Gall Bladder

11. The Gall Bladder

12. The Gall Bladder Function: Gallstones: 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

13. Gallstones Symptoms If gallstones block outflow of bile:
Abdominal discomfort
Pain
Heartburn
Indigestion
Acute inflammation

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

15. 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

16. 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

17. Laparoscopic Cholecystectomy

18. 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.

19. Did this technology diffuse slowly or rapidly?

20. An Important Innovator
Kurt Semm ( )
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

21. 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

22. 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

23. Public Response Semm: Gynecologists have “surgeon envy”
“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”

24. Did this technology diffuse slowly or rapidly?

25. Diffusion of Lap Choly

26. Diffusion of Lap Choly

27. 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

28. 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

29. 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

30. Using Gold to Detect Cancer
How long do you think it will be before we can test this in patients?
Normal
Abnormal

31. Using Gold to Feel Better
How long do you think it will be before we can test this in patients?

32. 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
's— Europe leads world in Technological advances
Many of these Technologies were the continuation of earlier advances in technology from China and elsewhere

33. 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)

34. "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."

35. 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

36. 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

37. 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

38. 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.
Assumption that Technologies of developed nations are essential to economic and Technological modernization of undeveloped countries is problematic

39. 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
Economic motive is important BUT it is still only a presumption of the likely success of a Technology

40. 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

41. 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

42. 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."