factors affecting the adoption of new cytology technologies

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EDITORIAL NOTE Factors Affecting the Adoption of New Cytology Technologies During the past decade there has been a major influx of new cytology technologies into the American cytology labora- tory. These technologies include liquid-based preparations, human papillomavirus (HPV) tests, and automated screen- ing instruments. Other technologies, such as ancillary tests (other than HPV tests), are also available, although not widely utilized at the current time. Mechanic 1 defines technologies as inputs (e.g., machines, procedures, strategies) organized to achieve specific out- comes. Advances in medical technologies are secondary to several factors such as developments in science, the value populations place on health, and incentives that society provides for stakeholders. 1 The development and use of cytology technologies depends on scientific progress, choice, activism, consumerism, and marketplace competi- tion. Mechanic 1 writes that once new preventive medicine technologies are introduced, patients may be placed on treatment trajectories that are difficult to control and receive interventions they may not need. This may result in signif- icant financial constraints placed on the medical system. Existing literature supports the view that managed care has contributed to slowing the adoption of new technologies, particularly the high-cost, high-profile technologies. 2 When monolayer technologies were first introduced, a financial disincentive existed in many markets, although this disin- centive no longer exists when certain conditions are met. It is unclear how managed care has affected the dissemination of other new cytology technologies. Hospitals, physicians, manufacturers, third-party payers, and patients all are factors in the demand for and diffusion of new technologies. 3 This is clearly the case for new cytology technologies, and it comes as a surprise to many pathologists and cytotechnologists that they are not the major drivers in determining the adoption of a new tech- nology. Medical professionals often believe that the pub- lished data should drive change or the adoption of a new technology. This is true to some extent, because the new technology must meet certain performance requirements in order to justify its use. 4 For new cytology technologies, pathologists have played a key role in the investigation of these performance requirements. However, once these re- quirements are satisfied, technology adoption may take place outside of laboratory control. The difficulty for pa- thologists is that insufficient published data exist in order to make decisions regarding how or why to adopt a new technology, because adoption is dependent on a number of factors other than data published in the pathology literature. For example, technology adoption may be driven by clini- cian and patient preferences rather than data on how the new technology actually affects laboratory practice. Thus, some cytologists have felt out of the loop in the adoption of monolayer technologies and have railed against the direct marketing of these technologies to clinicians and patients. However, such marketing is a means by which technologies are disseminated, although specific marketing methods are not without risk to manufacturers. In the current issue of Diagnostic Cytopathology, Parker et al. present data on the FocalPoint Primary Screening System (FPPS) produced by TriPath, Burlington, NC. 5 The FPSS is an example of an automated Pap test screening system, and this article focuses on the diagnostic perfor- mance characteristics of the instrument in SurePath liquid- based samples. The cytology community should be accus- tomed to the process of how new cytology technologies are introduced into the medical literature. At this stage, articles showing the efficacy of such technologies are often pub- lished, and authors who have some type of affiliation with the manufacturer publish many of the first articles. Later, authors with no affiliation publish similar articles on the performance characteristics. However, it should be remem- bered that these articles generally do not show how the technology will affect the cytology laboratory or even dic- tate whether a new technology will be adopted. A weakness of the pathology literature is that articles on new technologies generally report only on performance char- acteristics, such as diagnostic accuracy. In cervical cancer screening, metrics such as sensitivity and specificity are im- portant, because consumers desire a test that is at least as sensitive in detecting epithelial cell abnormalities as the older tests. For example, in the past decade the majority of the new cytology technology articles focused on liquid-based prepara- tions. For the most part, these articles showed that the use of liquid-based preparations resulted in an increase or an equiv- DOI 10.1002/dc.20034 Published online in Wiley InterScience (www.interscience.wiley.com). © 2004 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 30, No 2 105

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Page 1: Factors affecting the adoption of new cytology technologies

EDITORIAL NOTE

Factors Affecting the Adoption ofNew Cytology Technologies

During the past decade there has been a major influx of newcytology technologies into the American cytology labora-tory. These technologies include liquid-based preparations,human papillomavirus (HPV) tests, and automated screen-ing instruments. Other technologies, such as ancillary tests(other than HPV tests), are also available, although notwidely utilized at the current time.

Mechanic1 defines technologies as inputs (e.g., machines,procedures, strategies) organized to achieve specific out-comes. Advances in medical technologies are secondary toseveral factors such as developments in science, the valuepopulations place on health, and incentives that societyprovides for stakeholders.1 The development and use ofcytology technologies depends on scientific progress,choice, activism, consumerism, and marketplace competi-tion. Mechanic1 writes that once new preventive medicinetechnologies are introduced, patients may be placed ontreatment trajectories that are difficult to control and receiveinterventions they may not need. This may result in signif-icant financial constraints placed on the medical system.Existing literature supports the view that managed care hascontributed to slowing the adoption of new technologies,particularly the high-cost, high-profile technologies.2 Whenmonolayer technologies were first introduced, a financialdisincentive existed in many markets, although this disin-centive no longer exists when certain conditions are met. Itis unclear how managed care has affected the disseminationof other new cytology technologies.

Hospitals, physicians, manufacturers, third-party payers,and patients all are factors in the demand for and diffusionof new technologies.3 This is clearly the case for newcytology technologies, and it comes as a surprise to manypathologists and cytotechnologists that they are not themajor drivers in determining the adoption of a new tech-nology. Medical professionals often believe that the pub-lished data should drive change or the adoption of a newtechnology. This is true to some extent, because the newtechnology must meet certain performance requirements inorder to justify its use.4 For new cytology technologies,pathologists have played a key role in the investigation of

these performance requirements. However, once these re-quirements are satisfied, technology adoption may takeplace outside of laboratory control. The difficulty for pa-thologists is that insufficient published data exist in order tomake decisions regarding how or why to adopt a newtechnology, because adoption is dependent on a number offactors other than data published in the pathology literature.For example, technology adoption may be driven by clini-cian and patient preferences rather than data on how the newtechnology actually affects laboratory practice. Thus, somecytologists have felt out of the loop in the adoption ofmonolayer technologies and have railed against the directmarketing of these technologies to clinicians and patients.However, such marketing is a means by which technologiesare disseminated, although specific marketing methods arenot without risk to manufacturers.

In the current issue of Diagnostic Cytopathology, Parkeret al. present data on the FocalPoint Primary ScreeningSystem (FPPS) produced by TriPath, Burlington, NC.5 TheFPSS is an example of an automated Pap test screeningsystem, and this article focuses on the diagnostic perfor-mance characteristics of the instrument in SurePath liquid-based samples. The cytology community should be accus-tomed to the process of how new cytology technologies areintroduced into the medical literature. At this stage, articlesshowing the efficacy of such technologies are often pub-lished, and authors who have some type of affiliation withthe manufacturer publish many of the first articles. Later,authors with no affiliation publish similar articles on theperformance characteristics. However, it should be remem-bered that these articles generally do not show how thetechnology will affect the cytology laboratory or even dic-tate whether a new technology will be adopted.

A weakness of the pathology literature is that articles onnew technologies generally report only on performance char-acteristics, such as diagnostic accuracy. In cervical cancerscreening, metrics such as sensitivity and specificity are im-portant, because consumers desire a test that is at least assensitive in detecting epithelial cell abnormalities as the oldertests. For example, in the past decade the majority of the newcytology technology articles focused on liquid-based prepara-tions. For the most part, these articles showed that the use ofliquid-based preparations resulted in an increase or an equiv-

DOI 10.1002/dc.20034Published online in Wiley InterScience (www.interscience.wiley.com).

© 2004 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 30, No 2 105

Page 2: Factors affecting the adoption of new cytology technologies

alent detection of epithelial cell abnormalities compared to theuse of conventional preparations. It is notable that these tech-nologies have not been adopted in all nations, because factorsother than detection rates drive dissemination. Such factorsinclude cost, ability to perform ancillary tests on liquid-basedsamples, and clinician and patient preference.

The other type of article that has been published on the useof new cytology technologies is the cost-analytic article. Al-though there are several types of cost analyses, the mostcommonly published type is cost effectiveness, which mea-sures the associated costs of the technology in relation to aparticular benefit (e.g., life expectancy). In my opinion. thepublished cost-effectiveness articles on liquid-based technolo-gies have produced somewhat conflicting results, althoughthey have shown that liquid-based technologies are useful insome scenarios. Good cost-effectiveness articles are not alwayseasy to understand for the practicing clinician and are meant toguide rather than dictate policy. Because of the complexities ofmedical practice, cost-effectiveness studies cannot take intoaccount all aspects of patient care that are important for deci-sion-making regarding diagnostic testing. Although highly in-formative, cost-effectiveness studies are not without limita-tions. These studies have used metrics of cost and lifeexpectancy and have compared technologies in terms of cost-effectiveness ratios (the cost required to improve life expect-ancy by a specific amount). Most of the cost-effectivenessarticles were written from a societal viewpoint (much differentfrom a laboratory viewpoint). Cost-benefit studies of newcytology technologies (studies investigating other benefits ofcare such as patient preference) are particularly lacking.

It is notable that other aspects of new cytology technol-ogies generally are not investigated in our literature. Theseaspects include affect on workforce, difficulties in labora-tory adoption, affect on laboratory competition and profits,patient preference, and medical malpractice issues.6

Thus, cytology laboratories tend to adopt or reject newtechnologies based on limited evidence (consisting of compar-ative diagnostic accuracy studies and a few cost-effectivenessstudies) and forces outside their control. For example, manylaboratories attempt to “catch up” in the use of new technol-ogies because competitors are already using them. Alterna-tively, laboratories may be the first to adopt a new technologybecause of the competitive edge that technology may providewhen they are marketing their services for clinical business.Thus, one of the factors affecting the adoption of liquid-basedpreparations was that other laboratories were using them and,in order to maintain business, these technologies were adopted.This adoption is not the same as adoption because the pub-lished data indicated (or did not indicate) that these technolo-gies were better for patient care. Compounded with clinicianpressure for technology adoption is patient pressure for adop-tion, partly based on direct marketing to women who undergocervical cancer screening. Thus, the laboratories in which Ihave worked have made decisions on the adoption of new

cytology technologies partly based on performance data, butalso based on information related to laboratory profit andcompetition.

The extent to which automated screening instruments willbe adopted has yet to be determined, but my impression is thatif (or when) they are adopted, they will markedly affect thepractice of cytology. Currently, we have only speculative dataon the effects of automated instruments on cytology laborato-ries. Clearly, the issues are that we do not know how the use ofthese instruments will affect the cytotechnologist workforce,the competitive balance among laboratories, the financial sta-bility of laboratories, and the medical legal climate.

For the most part, these other issues are not the primarysource of concern for the manufacturers and, needless to say,they should not be. However, these other issues are importantto the cytology field because our concerns are different. Forexample, the future of cytotechnology most certainly is ofconcern to most in the cytology field. Cytotechnologist work-force issues have many relatively unstudied aspects, but thewidespread use of automated screening instruments clearlywould result in fewer screeners being needed. Many in thecytology field (including myself) have a strong bias in favor ofthe cytotechnology profession, which may result in a dialecticdepending on the cost issues related to automated screeninginstruments. This is a completely unstudied issue in our liter-ature. One reason for the lack of study is the lack of training inhealth services-related issues.

In conclusion, technologies are adopted for reasons partlybeyond the control of those who end up using them. We tendto focus on the performance characteristics of these technolo-gies and do not evaluate other aspects of how these technolo-gies will affect our laboratories. We believe we need to movebeyond the study of performance characteristics and learn tostudy the many ways in which these technologies will actuallyaffect our laboratories. In the end, how these technologies areadopted also will affect patient care.

Stephen S. Raab, M.D.

University of PittsburghPittsburgh, Pennsylvania

References1. Mechanic D. Socio-cultural implications of changing organizational

technologies in the provision of care. Soc Sci Med 2002;54:459–467.

2. Baker L. Managed care, medical technology, and the well being ofsociety. Top Magn Reson Imaging 2002;13:107–113.

3. Perry S. Diffusion of new technologies: rational and irrational. J HealthCare Technol 1984;1:73–88.

4. Gelijns A, Rosenberg N. The dynamics of technological change inmedicine. Health Aff 1994;13:28–46.

5. Parker EM, Foti JA, Wilbur DC. FocalPoint slide classification algo-rithms show robust performance in classification of high-grade lesionsin SurePath liquid-based cervical cytology slides. Diagn Cytopathol2002;30:107–110.

6. Battista RN. Innovation and diffusion of health related technologies. Aconceptual framework. Int J Technol Assess Health Care 1989:5:227–248.

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