The first paradox of innovation is the well-known problem that some new practices enjoy rapid uptake and diffusion throughout health systems, even when they are of limited benefit or unproven efficacy, or represent risks to patients, while other innovations that could secure better outcomes for patients never make it to the bedside.
The reasons why unproven innovations are sometimes rapidly adopted and implemented are becoming better understood.1 Some are rather like consumer fads—a new technology or therapy generates the excitement of newness and ‘must-have’—even before the evidence base has been firmly established. For example, percutaneous bladder neck suspension for stress incontinence was initially hailed as a great success and came into widespread use, but subsequent long-term follow-up of trials showed very disappointing outcomes.2 Some innovations diffuse rapidly because they offer hope in otherwise intractable or desperate situations where denying an available therapy is difficult. Examples include the use of laetrile for cancer, which, despite its enthusiastic promotion during the 1970s, lacked evidence of effectiveness—and indeed there is some evidence of toxicity.3 Some innovations are adopted and implemented because they have considerable face validity or intuitive appeal as plausible solutions, but later turn out to be wrong. Well-known examples include the use of antiarrhythmic agents in the treatment of myocardial infarction, and human albumin in treatment of critically ill patients.4 Organisations may also adopt innovations as a defence against anxiety, to guard against criticism that any failing was due to non-adoption. The widespread use of early warning scores and rapid response teams for deteriorating patients, despite only very equivocal evidence of benefit,5 may be an example of this.
The uptake of many dubious interventions relies on a form of magical thinking, where doing something is seen as better than doing nothing. The language used to promote innovations can be strongly implicated in such thinking. Terms such as ‘breakthrough,’ ‘radical,’ ‘new’ and even ‘innovative’ can stimulate consumer instincts, including those related to anticipated decision regret—where patients (and doctors) are reluctant to turn down any chance of possible improvement, even if there is only a small chance of success.6
Of course, rapid diffusion of innovation is also driven by profit-seeking behaviour. The engines of innovation may be commercial organisations prepared to resort to inventing ‘diseases’ (such as social anxiety disorder), repackaging cheap treatments as expensive ones for new markets (eg, using an expensive form of the cheap colon cancer drug Avastin for treating macular degeneration) or bringing to market technologies that offer only limited advantages over existing treatments. Many new devices—particularly diagnostic ones—need do no more than demonstrate that they comply with basic safety standards, and produce no evidence of efficacy. But organisations that stand to profit from the use of a new intervention may use sophisticated and aggressive marketing strategies, often enlisting patient pressure along the way and pressing political buttons to garner support. Clamour for therapies from desperate patients can be difficult to resist, as every health system in the world has discovered. Once institutions have invested in a new intervention, they then have a vested interest in recovering the costs, as the example of proton beam therapy for prostate cancer shows.
Diffusion of innovation without proven efficacy introduces several threats to quality improvement. Most obviously, such innovation may pose risks to patients. More insidiously, the deflection of effort and investment is a huge opportunity cost for health systems that undermines efforts to improve services. Further, the innovation may disrupt or displace procedures in areas that have been targets of quality improvement.
A mirror image to the problem of innovations without proven efficacy is the failure of diffusion of innovations that are of proven value. Here again, the evidence about what causes some efficacious innovations to remain unwrapped in the box is emerging. Some innovations—for example, pelvic floor exercises or improved hand hygiene practices—have little of the glamour of new technologies and generate little excitement. Others require a level of investment, training or reinforcement that healthcare organisations or practitioners may struggle to achieve. Some are simply tedious and inconvenient, or threaten existing interests. Many lack a well-funded advocate with access to modern marketing techniques and budgets; when there is no manufacturer who stands to profit, promotion may be lacklustre. Some fall victim to the problem that when there are plenty of areas where coercive forces are at work (eg, targets or standards against which performance will be rewarded), the spotlight naturally slips off those that are not the focus of such measures.
The appeal of the new and the rejection of the dull cannot be explained by focusing solely on individual and organisational behaviours. Complex systemic processes and institutional forces are at work. For example, decisions about which clinical research is done and which is published (and where) are implicated in determining whether an intervention ever comes to attention, what kinds of attention it gets and whether it gets adopted or implemented. Publication bias, which causes interventions to appear more useful than they really are, is just one of these systemic effects.