Ann Lennarson Greer

Bringing the patient back in. Guidelines, practice variations, and the social context of medical practice.

We challenge assumptions that have guided much research and policy aimed at understanding and reducing medical practice variation. Paramount is the focus on doctors as the cause of variation to the neglect of other possible influences. Some research literature suggests that patients, families, and the community context of practice may also influence treatment decisions. Failure to question present assumptions, despite weak evidence in support of them, may account for inability to explain persistent practice variation, develop appropriate implementable guidelines, or anticipate the effect on treatment decisions of greater patient involvement. In this paper, we discuss the weak response to the NIH Consensus Conference on early stage breast cancer because it may have reflected these problems. We urge a more complex and more empirical approach in explaining treatment choice and guidelines sensitive to the potential for value differences.

Medical Technology: Assessment, Adoption, and Utilization

Promotion of appropriate diffusion of technology in medicine is handicapped by: (1) thorny conceptual, ethical, and methodological problems in technology assessment; (2) a lack of consistent findings on the factors affecting technology adoption and utilization; and (3) a disturbing lack of apparent connection between assessment, adoption, and utilization. This paper reviews published work in these areas of inquiry, highlights areas of needed research, and suggests areas in which the health system of the Veterans Administration could make particularly valuable contributions.

Medical technology and professional dominance theory.

The expansion of medical technology in hospitals is commonly asserted to be a result of the preferences of medical doctors translated into organizational policies as a result of professional dominance in health care organizations. This paper examines the theoretical and empirical bases for hypotheses of professional dominance and the utility of these hypotheses in explaining hospital decisions to adopt new medical technologies. The analysis, which is based on 5 years of data collection including 378 personal interviews at 25 U.S. hospitals, indicates that appropriate application of the concept requires specification of the type of physician exercising influence and of the hospital decision systems within which it is exercised. Specification is needed because neither physicians nor hospitals are unitary categories when considered in relation to technology adoptions . In this paper, four categories of physicians are identified: community generalists, community specialists, referral specialists and hospital-based specialists. Members of these categories exhibit different skills and interests, different relationships to hospitals and hospital technologies, and differential access to the resources of organization influence including two unrelated to professional dominance. To understand the exercise of physician influence, it is further useful to differentiate three decision systems which review and pass judgement on different types of hospital technologies. They are: the medical-individualistic, the fiscal-managerial and the strategic-institutional. The three decision systems make decisions in accord with different values and goals and display different decision structures and dynamics. Ironically , the physicians who most clearly possess the resources of influence associated with professional dominance are centrally involved in only one of the three systems.(ABSTRACT TRUNCATED AT 250 WORDS)

From Planning to the Market: Changes in Hospital Approaches to Medical Technology

Medical procedures and technologies have expanded explosively over the last thirty years, presenting immense challenges to U.S. hospitals, typically free-standing nonprofit community institutions governed by boards of private citizens or religious orders. The potential of such hospitals to make ill-advised and costly decisions has been a constant theme of policy for two decades. A common perception is that hospital medical technologies diffuse among community hospitals too rapidly and too broadly, with too much costly duplication and without regard for under-use. This contributed in the 1970s to the introduction of governmental mechanisms for health planning and regulation and, in the 1980s, of prospective payment schemes and the market place for health care. This paper examines the technology decision processes of hospitals and hospital doctors between 1976 and 1990, the period when the U.S. experimented with governmental planning and regulation, then phased it out in favor of prospective payment and the market place for health care.

Governance dilemmas in an age of ambiguous authority

A convergence of functions, financing and governance arrangements between “public” and “private” sectors of society cloud the study and understanding of policy making, implementation and evaluation. Forces creating and shaping the interpenetrated society are trends toward professionalism and corporatism. The health industry provides an example. Increasingly, but with little formal guidance from political theory, the American system has authorized privately constituted citizen governing boards to spend tax dollars, make and implement policy choices, and evaluate outcomes. This essay argues for closer examination of the nature of representation and accountability in these little studied creatures of governance and introduces the subsequent articles addressed to the subject.