Therapeutic innovation in high-prevalence chronic diseases: Challenges and opportunities for specialist care models

Therapeutic innovation is expected to change if not disrupt present care models for several chronic diseases in the coming years, as suggested by recent clinical trials. New drugs that anticipate and possibly delay the full expression of a disease will likely face some common challenges, such as the need of designing and implementing large scale interventions; the necessary engagement of multiple specialties for both diagnosis and treatment; the shift from specialist to non-specialist interventions and secondary prevention. Building on the case of HCV and other innovation in hepatology, we discuss common challenges caused by disruptive change that other chronic conditions faced in the past. The recent history of hepatology shows interesting examples of disruptive innovations that completely reverted traditional treatment approaches. As we learned from the slow early diffusion of antiviral drugs, without a clear information and a prompt design of the appropriate delivery modalities, the effectiveness of new treatments is undermined and care risk to be postponed for long time. This implies the definition of (i) new service models diversified by care phases and patients' target; (ii) horizontal integration: to go beyond the professional boundaries to build solid alliances; (iii) vertical integration between primary and secondary care.

Unpacking the 'process of sustaining'-identifying threats to sustainability and the strategies used to address them: a longitudinal multiple case study

BACKGROUND

Although sustainability remains a recognised challenge for Quality Improvement (QI) initiatives, most available research continues to investigate sustainability at the end of implementation. As a result, the learning and continuous adjustments that shape sustainability outcomes are lost. With little understanding of the actions and processes that influence sustainability within QI initiatives, there is limited practical guidance and direction on how to enhance the sustainability of QI initiatives. This study aims to unpack the 'process of sustaining', by exploring threats to sustainability encountered throughout the implementation of QI Initiatives and identifying strategies used by QI teams to address these threats over time.

METHODS

A longitudinal multiple case study design was employed to follow 4 QI initiatives over a 3-year period. A standardised sustainability tool was used quarterly to collect perceptions of sustainability threats and actions throughout implementation. Interviews (n=38), observations (32.5 h), documentary analysis, and a focus group (n=10) were conducted to enable a greater understanding of how the process of sustaining is supported in practice. Data were analysed using the Consolidated Framework for Sustainability (CFS) to conduct thematic analysis.

RESULTS

Analysis identified five common threats to sustainability: workforce stability, improvement timelines, organisational priorities, capacity for improvement, and stakeholder support. Each of these threats impacted multiple sustainability constructs demonstrating the complexity of the issues encountered. In response to threats, 12 strategies to support the process of sustaining were identified under three themes: engagement (five strategies that promoted the development of relationships), integration (three strategies that supported initiatives to become embedded within local systems), and adaptation (four strategies that enhanced understanding of, and response to, emergent conditions and contextual needs).

CONCLUSIONS

Sustaining improvements from QI initiatives requires continuous investment in relationships, resilience to integrate improvements in local systems, and flexibility to understand emergent conditions. Findings provide practitioners, funders, and researchers with a better understanding of, and preparation for, the threats associated with sustaining improvements from QI initiatives and offer insight into specific actions that can be taken to mitigate these risks. This learning can be used to inform future initiative design and support, to optimise the sustainability of healthcare improvements.

TRIAL REGISTRATION

Not applicable.

Appropriating integrated performance management tools in healthcare: a sociomaterial work story

PURPOSE

The purpose of this paper is to explore the appropriation of control rooms based on value-based integrated performance management tools implemented in all publicly funded health organizations in Quebec (Canada) as a form of legitimate sociomaterial work.

DESIGN/METHODOLOGY/APPROACH

Multi-site organizational ethnographic case studies in two Integrated health and social services centers, with narrative process analysis of triangulated qualitative data collected through non-participant observation (163 h), individual semi-structured interviews (N = 34), and document review (N = 143).

FINDINGS

Three types of legitimate sociomaterial work are accomplished when actors appropriate control rooms: 1) reformulating performance management work; 2) disrupting accountability work and; 3) effecting value-based integrated performance management. Each actor (tools, institutions and people) follows recurrent institutional work-paths: tools consistently engage in disruptive work; institutions consistently engage in maintaining work, and people consistently engage in creation work. The study reveals the potential of performance management tools as "effective integrators" of the technological, managerial, policy and delivery levels of data-driven health system performance and improvement.

PRACTICAL IMPLICATIONS

This paper draws on theoretically informed empirical insights to develop actionable knowledge around how to better design, implement and adapt tool-driven health system change: 1) Packaging the three agents of data-driven system change in health care: tools, institutions, people; 2) Redefining the search for performance in health care in the context of value creation, and; 3) Strengthening clinical and managerial relevance in health performance management practice.

ORIGINALITY/VALUE

The authors aim to stimulate new and original scholarship around the under-theorized concept of sociomaterial work, challenging theoretical, ontological and practical conceptions of work in healthcare organizations and beyond.

The development of complex and controversial innovations. Genetically modified mosquitoes for malaria eradication

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Using the example of mosquitoes that are genetically modified for malaria eradication through gene drive methods, a scientifically complex ‘living technology’, we show how complexity, uncertainty and risk can propel NPD processes towards a linear sequence of stages.

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Although the need to control risks associated with gene drive technology imposes linearity to the NPD process, there are possibilities for deviation from a structured sequence of stages. This is due to the effects of feedback loops in the wider system of evidence creation and learning at the population and governance levels, which cumulatively impact on acceptance of the innovation.

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The NPD and adoption processes involved in the use of gene drive technology are closely intertwined, and the endpoint for R&D and beginning of ‘mainstream’ adoption and diffusion are unclear.

When there is significant uncertainty in an innovation project, research literature suggests that strictly sequencing actions and stages may not be an appropriate mode of project management. We use a longitudinal process approach and qualitative system dynamics modelling to study the development of genetically modified (GM) mosquitoes for malaria eradication in an African country. Our data were collected in real time, from early scientific research to deployment of the first prototype mosquitoes in the field. The 'gene drive' technology for modifying the mosquitoes is highly complex and controversial due to risks associated with its characteristics as a living, self-replicating technology. We show that in this case the innovation journey is linear and highly structured, but also embedded within a wider system of adoption that displays emergent behaviour. Although the need to control risks associated with the technology imposes a linearity to the NPD process, there are possibilities for deviation from a more structured sequence of stages. This arises from the effects of feedback loops in the wider system of evidence creation and learning at the population and governance levels, which cumulatively impact on acceptance of the innovation. The NPD and adoption processes are therefore closely intertwined, meaning that the endpoint for R&D and beginning of 'mainstream' adoption and diffusion are unclear. A key challenge for those responsible for NPD and its regulation is to plan for the adoption of the technology while simultaneously conducting its scientific and technical development.

Framing the Shades of Sustainability in Health Care: Pitfalls and Perspectives from Western EU Countries

Sustainability is momentous for the appropriate functioning of health care systems. In fact, health and sustainability are two strictly related values, which could not be separately sought. While studies discussing the contextualization of this issue with respect to the distinguishing attributes of health care systems are rapidly blooming, there is still little agreement about what is ultimately meant by sustainability in the health care arena. On the one hand, attention is primarily focused on the proper use of available financial resources; on the other hand, people engagement and empowerment are gradually arising as a crucial step to enhance the viability of the health care system. This paper tries to identify, from a conceptual point of view inspired by the European integrative movement, the different shades of sustainability in health care and proposes a recipe to strengthen the long-term viability of health care organizations. The balanced mix of financial, economic, political, and social sustainability is compelling to increase the ability of health care organizations to create meaningful value for the population served. However, the focus on a single dimension of sustainability is thought to engender several side effects, which compromise the capability of health care organizations to guarantee health gains at the individual and collective levels. From this standpoint, further conceptual and practical developments are envisioned, paving the way for a full-fledged understanding of sustainability in the health care environment.