Explaining Diffusion Patterns for Complex Health Care Innovations :

This paper describes the results of a study that examines how formal analysis is actually used in practice in three different organizations. Four main groups of purposes for formal analysis--information, communication, direction and control, and symbolic purposes--are identified and related to the nature of the social and hierarchical relationships between those who initiate analysis, those who do it, and those who receive it. It is concluded that, far from being antithetical as often assumed, formal analysis and social interaction are inextricably linked in organizational decision making and that different structural configurations may generate different patterns of use of analysis.

Results of randomized clinical trials of assertive community treatment for seriously mentally ill patients published between 1990 and 1994 are reviewed to synthesize the state of knowledge about this research and to clarify continuing research directions. Randomized trials of interventions that used treatment principles and practices consistent with the Program for Assertive Community Treatment model or close adaptations whose results were published since 1990 were identified by literature searches using MEDLINE and PsychLit and by contact with investigators of ongoing trials. Controlled clinical trials have been conducted with a wide range of severely mentally ill populations, including patients in Great Britain, patients with recent-onset schizophrenia, veterans, dually diagnosed clients, and homeless persons. Methodological improvements in some studies include increased attention to monitoring the experimental and comparison interventions, as well as larger sample sizes and longer duration of the clinical trials than in earlier efficacy trials. Strong positive effects of assertive community treatment on hospital days and on patient and family satisfaction were found. Gains in functional outcomes, such as employment, may require interventions specifically targeted to these outcomes. Questions about the role of assertive community treatment as time-limited treatment, as an adjunct to other services and treatment, or as a comprehensive and continuous service system for adults with severe mental illness require further research. The growing research base should provide valuable information on costs, outcomes, and indications for assertive community treatment that can be evaluated by policy-makers.

This paper contrasts a dynamic and interactive view of technological change with the linear model of medical innovation that is still so deeply ingrained in many policy discussions. In particular, it focuses on the role of feedback mechanisms between the users and the developers of medical technology and the demand and supply forces (including competition among medical specialties) determining this feedback. It explores three distinct mechanisms by which technological change may contribute to rising health care spending: intensity of use of existing technology, introduction of new technologies, and expanded application of these new technologies.