Factors Associated with De-Adoption

CLAHRC WM News Blog readers know about factors associated with adoption of new technology. Where the treatment is within the gift of a single clinician, then the following barriers / facilitators determine the probability of adoption:

1. The strength of the evidence.
2. Prior beliefs – when a person has no strong opinion, then evidence of given strength will be more influential than when it must compete with strong prior beliefs.[1] For example, I would take some convincing that homeopathy is effective.
3. Psychological approach – when the new evidence requires practitioners to give up something they are accustomed to doing, then change is harder to achieve. (X-rays came into routine use within four years of Röentgen’s discovery, while antisepsis took over a generation.)
4. Psychological predisposition – according to Rogers, some people are psychologically predisposed to be early adopters or laggards (but this can be specific to the technology concerned).
5. Role models and other forms of influence from the social environment.
6. The presence of subconscious ‘clues’ in the environment – nudge theory.[2]
7. Financial incentives at the personal level – but watch out for perverse effects.

When adoption is not in the gift of individual clinicians, the organisation as a whole has to respond. Many barriers / facilitators can be encountered.

1. Changing supply chains so that the appropriate technology is available and can be maintained. This is a large barrier in low-income countries.
2. Arranging for training / education when a new technology supplants an existing technology.
3. Support across the organisational hierarchy to send out the right social ‘signals’ (see also above).
4. Co-ordination across barriers – different professions and across organisational boundaries. We have discussed barriers and facilitators to cross-border facilitation in previous blogs.[3]
5. Financial incentives at the organisational level,[4] although again these can have negative side-effects.[5] [6]
6. Fit with established workflows and the immediate demands of a situation – a particular problem with IT, as described in previous blogs.[7] [8] Put simply, the more disruptive the technology, the harder change is to achieve and the greater the risk that any adoption will introduce new risks.

All of the above problems require an organisation to have time and people to help solve problems – the concept of absorptive capacity, which has been explored in our CLAHRC.[9]

But what about de-adoption; does that have different features? This topic was studied in a recent issue of the BMJ.[10] They looked at different individual features associated with de-adoption of carotid revascularisation procedures that are falling from vogue, but which are still indicated in some cases. Here clinicians should ‘exnovate’ by scaling back rather than eschewing the procedure completely. More experienced physicians and smaller practices were associated with faster exnovation, but patient factors, strangely, were not. The authors suggest that early adopters tend to be early de-adopters. Far from convincing me that there is something special about de-adoption / exnovation, the evidence actually presented did not suggest that the factors are qualitatively different to those associated with adoption in the first place.

— Richard Lilford, CLAHRC WM Director

References:

1. Johnson SR, Tomlinson GA, Hawker GA, Granton JT, Feldman BM. Methods to elicit beliefs for Bayesian priors: a systematic review. J Clin Epidemiol. 2010; 63(4): 355-69.
2. Lilford RJ. Demystifying Theory. NIHR CLAHRC West Midlands News Blog. 10 April 2015.
3. Lilford RJ. Evaluating Interventions to Improve the Integration of Care (Among Multiple Providers and Across Multiple Sites). NIHR CLAHRC West Midlands News Blog. 10 February 2017.
4. Combes G, Allen K, Sein K, Girling A, Lilford R. Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates. Implement Sci. 2015; 10: 148.
5. Lilford RJ. Financial Incentives for Providers of Health Care: The Baggage Handler and the Intensive Care Physician. NIHR CLAHRC West Midlands News Blog. 25 July 2014.
6. Lilford RJ. Two Things to Remember About Human Nature When Designing Incentives. NIHR CLAHRC West Midlands News Blog. 27 January 2017.
7. Lilford RJ. Introducing Hospitals IT Systems – Two Cautionary Tales. NIHR CLAHRC West Midlands News Blog. 4 August 2017.
8. Lilford RJ. New Framework to Guide the Evaluation of Technology-Supported Services. NIHR CLAHRC West Midlands News Blog. 12 January 2018.
9. Currie G, Croft C. Enhancing absorptive capacity of healthcare organizations: The case of commissioning service interventions to avoid undesirable older people’s admissions to hospitals. In: Swan J, Newell S, Nicolini D. Mobilizing Knowledge in Healthcare. Oxford: Oxford University Press; 2016. p.65-81.
10. Bekelis K, Skinner J, Gottlieb D, Goodney P. De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study. BMJ. 2017; 359: j4695.