Diffusion of Innovations: The Introduction And Impact of The Chest Pain Emergency Department And Its Comparison to Coronary Care Unit Development
Derek G. Gill, PhDProfessor and Chair
Department of Sociology and Anthropology
University of Maryland Baltimore County
Baltimore, MD
Quick Overview
Medicine is often said to be the oldest profession, yet medicine's ability to intervene effectively in the treatment of diseases is of recent origin. Henderson, a historian and medical doctor, argued that it was not until 1914 that the average patient with an average disease interacting with an average physician stood a better than 50/50 chance of benefitting from the encounter.
Since Henderson's day, the scientific revolution has increased in pace and achievement. Innovations in medical practice have multiplied dramatically, but their diffusion throughout the medical and social systems is influenced by social processes. Coronary care units (CCUs) were developed under a reimbursement mechanism based on a cost-plus formula. Chest pain emergency departments (CPEDs) were developed and diffusion occurred under very different reimbursement procedures. Moreover, CCUs entered hospital medical practice before they demonstrated an ability
to intervene effectively in heart disease. From their onset, CPEDs made theoretical sense once the principles of thrombolytic treatment were understood and thrombolytic therapy's ability to prevent muscle damage was established.
It will be argued that the spread of CPEDs is more in keeping with the relationships between scientific knowledge, technologic innovation and clinical efficacy and the necessity to control the costs of medical care than was the case of the diffusion of CCUs.
Diffusion of Innovations: An Early Example
The most extensive discussion of the diffusion of innovations is in the work of EM Rogers. (1) Rogers defined diffusion "as the process by which (1) an innovation; (2) is communicated through certain channels; (3) over time; (4) among the members of a social system."An innovation usually has two identifiable components: a technologic component, which facilitates a change in circumstance, and an idea or theory, which posits a particular outcome.
Snow's removal of the handle at the Broad street pump was successful in a small social system (the geographic limitations of the catchment area in which he practiced) but it was not adopted elsewhere. Chadwick's Report on the Sanitary Condition of the Labouring Population of Great Britain, (2) which linked unhygienic conditions to the spread of infectious diseases, was ineffective until the late 1870s. Some public health measures were introduced in midcentury, perhaps aided by Engels' expose (3) of the suffering and the relationships between poverty and disease among the "lower orders," which he documented but were limited in application and subsequently withdrawn. The failure of these early attempts to introduce public health reforms was associated with their lack of an adequate theoretical basis. Moreover, innovations, if they are to be successful, must also satisfy other criteria, specifically the social, political, and economic needs of the social system when new procedures are proposed.
What were the circumstances that facilitated the introduction of the Public Health Act in Britain in 1875? While Pasteur's work on fermentation may have had some impact, more mundane principles of economic advantage may also have influenced the arguments in favor of sanitary reform. By the last quarter of the 19th century, the industrial revolution in Great Britain had passed into the consolidation and routinization phase. Clearly, the advanced technology phase was yet to come, but the basic methods of mass production were already established in manufacturing and extraction industries. Dips in the trade cycle were accommodated by firing workers or placing the work force on short time. In the peaks of the trade cycle, the continuing participation of the work force was essential for efficient and profitable production. Epidemic diseases became a real threat to the maintenance of profits. Once these associations were acknowledged, capitalists had solid grounds for supporting sanitary reform. Moreover, disease in the work force could be interpreted as an indirect cost of production; if part of these costs could be passed onto the taxpayers, then all to the good.
As routinization of the industrial revolution continued and the role of the state expanded, the middle class grew accordingly. This new class could escape the unsanitary conditions in the towns by migrating to the suburbs, but epidemic diseases often did not recognize such barriers.
The working class, which was most likely to benefit from sanitary reform, was yet to mount a powerful and significant political and representative protest movement. Nevertheless, the foundations for working-class representation were emerging as workingmen's clubs embraced socialism and gained experience in organizing collective action; also of importance were the cooperative movements, and the insurance activities of friendly societies, including unemployment pay, and health and death benefits.
Sanitary reform met the needs of many segments of British society in the late 19th century. Manufacturers anticipated improvements in the health of the working class as a guarantee of profits, and the costs of sanitary reform could be passed on to the private sector. The establishment saw such reform as contributing to the maintenance of the hegemony of the politically dominant by reducing the potential for working-class protest. The middle class was pleased to see
the incubators of infectious diseases eradicated. Working-class groups ultimately enjoyed a better quality of life as infectious disease epidemics declined. However, it is important to note that the sanitary reforms were introduced before the germ theory of disease was fully developed.
Quick Overview
Diffusion of Innovation: The Chest Pain Emergency Room
The first CPED was opened at St. Agnes HealthCare, Baltimore, by Raymond Bahr in 1981. The initial idea for CPEDs emerged from Bahr's clinical experience. Bahr recognized that among his patients ischemic heart disease was often preceded by complaints of mild stuttering chest pain or discomfort. Bahr's earlier experience was gained in a traditional CCU. The early CCUs were based upon intravenous administration of lidocaine and the application of electric shock (defibrillation) to the chest wall.Procedures to monitor the heart beat became possible with the development and perfection of the electrocardiogram. Again, knowledge and an appropriate technology came together to produce a diagnostic capability and treatment for heart disease. The conditions now existed for the rapid diffusion of an innovation-the establishment of CCUs in all major hospitals.
CCUs required enormous capital expenditure, and an effective modus operandi dictated 24-hour coverage. CCUs spread rapidly throughout the United States before their effectiveness in treating heart disease had been established. Fear of heart attacks probably aided the spread of these units; 345 U.S. hospitals had opened CCUs by 1974. (4) yet other factors were equally important.
If the diffusion of CCUs was to be successful, some mechanism for financing both capital and operating costs had to be secured. The fee-for-services process for paying medical care costs was well established by the late sixties. Hospitals were reimbursed on a cost-plus basis and physicians on a formula of "usual and customary" charges. These mechanisms, together with the emotional appeal of a system that claimed to treat heart attacks, were sufficient to ensure the spread of CCUs.
Nevertheless, Bahr could not shake his conviction that the key to the treatment of myocardial infarctions (MIs) was to be found in the treatment of patients at an earlier stage of the disease. Through focused interviews of MI patients who survived long enough to be treated in the hospital, Bahr elicited histories of earlier chest pain. For many patients, denial and fear of hospitals prevented earlier self-referral, but some patients had the prescience to present for hospital care at an early stage. What principles for organizing the medical care of such patients would maximize their chances of surviving an MI and how should false-positives be ruled out?
The principles and organizational structure of CPEDs are now documented in the literature and need no further explanation here. Since 1981 the spread of CPEDs has been significant, and today more than 800 hospitals have or are about to introduce such units. The diffusion of CPEDs has not, however, been as rapid as the earlier successes of CCUs. Why?
It is now accepted that innovations in medical treatment should not be introduced until their effectiveness has been demonstrated by a randomly controlled clinical trial (RCT). Such premises reflect the increasing dependenceupon scientism in the medical community, which may protect the public from, for example, the terrible consequences of the thalidomide tragedy.
But RCTs themselves are subject to constraints, both economic and ethical. Fortunately, most diseases affect small numbers of people and it is often necessary to include numerous patients in an RCT if the outcomes are to be statistically significant. Such trials are very expensive. Many such trials are terminated if the early findings suggest a positive outcome. Such an outcome suggests the theoretical foundation for the innovation was sound and that the new procedure should be accepted into routine practice without further empirical support. Recently, Rawles et al have stated: But again an economic factor also slowed the diffusion of CPEDs. By the 1980s, the increase in medical care costs at 10% per annum were generating concern in industry, government, and the insurance industry. These pressures led the government to switch from retrospective to prospective payment mechanisms to reimburse Medicare and to reduce hospital length of stay. The pressure to control costs also promoted arguments in favor of extending the principle of managed care across the whole spectrum of medical care.
In this economic climate a medical innovation requiring a modest increase in capital and operating costs was unlikely to attract support unless the reasons for so doing were overwhelming. I shall now argue that this is the case with respect to CPEDs for sound medical and economic reasons.
The medical argument was settled by the publication of 1-year data from the Grampian Region Early Anistreplase Trial (GREAT). (5) Early (prehospital) thrombolysis resulted in a halving of the mortality rate from acute MI among patients from Scotland. The theoretical basis for early thrombolytic therapy has now been established empirically.
The economic argument in support of the CPED concept is provided by a PhD dissertation by Kathleen M. White entitled A Cost-Effectiveness analysis of the Treatment of Chest Pain in a chest Pain emergency room vs. A Traditional emergency Department. Of 911 patients complaining of chest pain admitted to the CPED and the ED, 670 cases were available for cost-effectiveness analysis by regression analysis after the subjects were matched for analysis by age, gender, race, and for similar admitting diagnoses.
The finding was that there was a significant cost-saving for patients treated in the CPED compared with the hospital ED. This CPED 'benefit' was calculated by subtracting the total cost (CPED/ED + admission) from the cost incurred in the CPED/ED phase. This showed a reduction of $600 per patient for the patients treated at the CPED hospital.
The most likely explanation for these findings is that the hospital ED admitted patients to the CCU from the ED who did not warrant further investigation. The ED physicians were behaving risk adversely by admitting patients to the CCU who probably did not need to be there. Monitoring and evaluation of patients presenting with chest pain in the CPED was both effective and cheaper than the same process conducted in a CCU. Crumlish (6) has suggested a false-positive admission rate to CCUs of 60% to 65%, with an estimated cost for these noncardiac admissions of $1.5 to $3.5 billion annually in the United States. If hospital administrators, managed care proponents, and medical insurance executives become aware of these findings we shall soon see CPEDs in virtually every American hospital!
Quick Overview
The Future of Early Thrombolytic Treatment
Both the theoretical and empirical evidence in favor of early treatment with thrombolytic agents for a wide range of acute MIs has now been established. Early application of such therapies has considerable potential for decreasing the cost of treatment of acute MIs. The problem is to get the treatment to patients early enough for them to benefit from thrombolysis. The St. Agnes group has initiated a community awareness program to educate the public of the advantages of early referral to a CPED. Other interested communities can adopt the Baltimore model or develop their own programs.Unlike the Scotland example, where chest pain calls are directed to general physicians who make house calls, in the United States ambulances are dispatched to people's houses to respond to medical emergencies such as chest pain. Perhaps it is time to think again about Pantridge and Geddes' (7) notion of the "coronary care ambulance." Could we design protocols for paramedics to examine chest pain patients in their homes and administer thrombolytic agents before the patient is transported to hospital? Alternatively, could paramedics after examining patients report their findings to physicians in the ED with cardiac training through a radio-telephone link and then administer thrombolysis if the physician agreed? The continuing need for cost-effective medical care may encourage the diffusion of such innovation.
Final Thoughts
My purpose in this paper has been to examine innovation in medicine in the context of the social, economic, and scientific climates in which they occur. It is difficult to escape the conclusion that theoretical constructs play an important role in the development of innovations which lead to an action-the removal of the Broad street pump handle. In the case of sanitary reform, socioeconomic factors supported innovations whose theoretical basis was emergent and whose empirical support was limited. CCUs were introduced while the theoretical and empirical support for them was limited, but economic factors encouraged their adoption. CPEDs were introduced on reasonable theoretical grounds but their diffusion was limited because the social, economic, and scientific climates were less favorable than had been the case with CCUs. Today the economic climate has changed and will now promote the spread of CCUs. If we had paid more attention to the strong theoretical arguments in support of CPEDs in the 1980s, they might have been adopted earlier. Theoretical progress is essential to the process of innovation and we would do well to recognize this fact in the future.References
1. Rogers EM (1983). Diffusion of Innovations. The Free Press, New York.2. Chadwick E (1963). Report on the Sanitary Conditions of the Labouring Population of Great Britain. Edited with an Introduction by MW Flinn. Edinburgh University Press, Scotland.
3. Engles R (1952). The Conditions of the Working Class in England in 1844. George Allen and Unwin, London.
4. Waitzkin H (1983). The Second Sickness. Contradictions of Capitalist Health Care. The Free Press, London & New York.
5. Rawles J on behalf of the GREAT Group. Halving of mortality at 1 year by domiciliary thrombolysis in the Grampian region early anistreplase trial (GREAT). J Am Coll Cardiol. 1994;23:1-5.
6. Crumlish C. Education is the key to heart attack alert program. The Amer Nurse. 1995;30.
7. Pantridge JF, Geddes JS. A mobile intensive care unit in the management of myocardial infarction. Lancet. 1967;II:274.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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