Commentary: Academic health centers and comparative effectiveness research: opportunities and challenges

Teaching Hospitals and the Disconnect Between Technology Adoption and Comparative Effectiveness Research: The Case of the Surgical Robot

The surgical robot, a costly technology for treatment of prostate cancer with equivocal marginal benefit, rapidly diffused into clinical practice. We sought to evaluate the role of teaching in the early adoption phase of the surgical robot. Teaching hospitals were the primary early adopters: data from the Healthcare Cost and Utilization Project showed that surgical robots were acquired by 45.5% of major teaching, 18.0% of minor teaching and 8.0% of non-teaching hospitals during the early adoption phase. However, teaching hospital faculty produced little comparative effectiveness research: By 2008, only 24 published studies compared robotic prostatectomy outcomes to those of conventional techniques. Just ten of these studies (41.7%) were more than minimally powered, and only six (25%) involved cross-institutional collaborations. In adopting the surgical robot, teaching hospitals fulfilled their mission to innovate, but failed to generate corresponding scientific evidence.

Improving hospital care: are learning organizations the answer?

PURPOSE

Hospital leaders are being challenged to become more consumer-oriented, more interprofessional in their approach to care and more focused on outcome measures and continuous quality improvement. The concept of the learning organization could provide the conceptual framework necessary for understanding and addressing these various challenges in a systematic way. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

A scan of the literature reveals that this concept has been applied to hospitals and other health care institutions, but it is not known to what extent this concept has been linked to hospitals and with what outcomes. To bridge this gap, the question of whether learning organizations are the answer to improving hospital care needs to be considered. Hospitals are knowledge-intensive organizations in that there is a need for constant updating of the best available evidence and the latest medical techniques. It is widely acknowledged that learning may become the only sustainable competitive advantage for organizations, including hospitals.

FINDINGS

With the increased demand for accountability for quality care, fiscal responsibility and positive patient outcomes, exploring hospitals as learning organizations is timely and highly relevant to senior hospital administrators responsible for integrating best practices, interprofessional care and quality improvement as a primary means of achieving these outcomes.

ORIGINALITY/VALUE

To date, there is a dearth of research on hospitals as learning organizations as it relates to improving hospital care.

Clinical designs of recent robot rehabilitation trials

Rehabilitation robots are increasingly being tested and promoted for clinical neurorehabilitation. Compared with conventional and manual methods, robots allow for a variety of advantages, particularly in the areas of interventional control and the ability to provide a high volume of facilitated movement. Since 1997, there have been more than 60 clinical trials reporting the use of two dozen different robots for neurorehabilitation. Although there are a number of smaller pilot studies, there are only few larger clinical trials. There may be a number of reasons why pilot robot studies do not materialize into larger studies. Beyond devices that failed to perform as intended, what are the clinical design issues that have limited these studies? Some basic considerations include randomization, inclusion of a control group, power calculation based on a clinically meaningful outcome, and finally, reproducible descriptions of the intervention being tested. Although many of these issues are general challenges presented for all rehabilitation studies, there are clinical design features that would likely greatly improve interpretation of results and better position robot devices toward the next clinical trial step. On the other hand, the absence of these elements, even in the setting of a pilot study, may significantly hamper the interpretation of results and not yield sufficient information on treatment effects, adverse event rates, dropout rate, and so on, to allow further testing to proceed to follow-up Food and Drug Administration phase II and III studies. Development of rehabilitation robots for clinical use needs to occur hand in hand with well-conducted clinical trials to provide evidence of efficacy while also taking into account costs.