New technologies meeting old professional boundaries: the emergence of carotid artery stenting

Barriers and facilitators to the uptake of computerized clinical decision support systems in specialty hospitals: protocol for a qualitative cross-sectional study

BACKGROUND

Computerized clinical decision support systems (CDSSs) have been shown to improve the efficiency and quality of patient care by connecting healthcare professionals with high quality, evidence-based information at the point-of-care. The mere provision of CDSSs, however, does not guarantee their uptake. Rather, individual and institutional perceptions can foster or inhibit the integration of CDSSs into routine clinical workflow. Current studies exploring health professionals' perceptions of CDSSs focus primarily on technical and usability issues, overlooking the social or cultural variables as well as broader administrative or organizational roles that may influence CDSS adoption. Moreover, there is a lack of data on the evolution of perceived barriers or facilitators to CDSS uptake across different stages of implementation.

METHODS

We will conduct a qualitative, cross-sectional study in three Italian specialty hospitals involving frontline physicians, nurses, information technology staff, and members of the hospital board of directors. We will use semi-structured interviews following the Grounded Theory framework, progressively recruiting participants until no new information is gained from the interviews.

DISCUSSION

CDSSs are likely to become an integral and diffuse part of clinical practice. Various factors must be considered when planning their introduction in healthcare settings. The findings of this study will guide the development of strategies to facilitate the successful integration of CDSSs into the regular clinical workflow. The evaluation of diverse health professionals across multiple hospital settings in different stages of CDSS uptake will better capture the complexity of roles and contextual factors affecting CDSS uptake.

National trends in carotid artery revascularization surgery

Object

Several randomized trials have emerged with conflicting data on the overall safety of carotid artery stenting (CAS) in comparison with carotid endarterectomy (CEA). The authors hypothesize that changes in national trends correspond to publication of randomized trials, including an increase in utilization of CAS after publication of trials favorable to CAS (for example, Carotid and Vertebral Artery Transluminal Angioplasty Study [CAVATAS] and Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy [SAPPHIRE]) and decrease in utilization of CAS after publication of trials favorable to CEA (for example, Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA3-S] and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy [SPACE]).

Methods

The Nationwide Inpatient Sample was obtained for the years 1998–2008. Individual cases were isolated for principal diagnosis of unilateral or bilateral carotid artery stenosis or occlusion undergoing CEA or CAS. The percentage of CAS for all carotid revascularization procedures was calculated for each year. Perioperative inpatient morbidity, including stroke or death, were calculated and compared.

Results

The percentage of patients undergoing CAS increased yearly from the start of the observed period to the end, with the exception of a decrease in 2007. The peak utilization of CAS for carotid artery revascularization procedures was 15% of all cases in 2006. The stroke or death rate was consistent at 5% among all patients undergoing CEA for all years, while the incidence of stroke or death decreased among patients undergoing CAS from 9% in 1998 to 5% in 2008.

Conclusions

The practice of CAS in the US is expanding, from less than 3% of all carotid artery revascularization procedures to 13% in 2008. The utilization of CAS was seen to correlate with publication of randomized trials. Utilization nearly doubled in 2005 after publication of the CAS-favorable SAPPHIRE in 2004, and decreased by 22% after publication of the CEA-favorable EVA-3S and SPACE in 2007. With the publication of Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), the authors predict a resultant increase in the rate of CAS for carotid artery disease in the upcoming years.

Risky Business: How Professionals and Professional Fields (Must) Deal with Organizational Issues

As professionals belong to occupational systems but also increasingly work inside organizations, new linkages between occupational and organizational domains are required, but they are difficult to develop. Occupational principles and professional standards are usually considered to be at odds with managerial and organizational control principles. This generates academic and practical dualisms. Either a return to professionalism is advocated in order to protect occupational spaces and ‘rescue’ professional work, or there is a move beyond professionalism in order to restrict autonomies and discipline professional work. This article argues that both stances are unsatisfactory and that new forms of organized professionalism are called for. Changing circumstances force professional services to respond to external changes that call for organizational capacities, also inside professional domains: (a) professionals develop new work preferences and seek organized work conditions; (b) professionals face new cases, which are difficult to categorize and call for well-organized multi-professional acts; (c) due to critical attention for case treatment and incidents, professionals face new risks that have to be managed. The article shows how these realities are incorporated in professional practices – albeit slowly – and it draws normative conclusions. Professionals must take organizing and managing more seriously and will have to develop organizational capacities. In addition, connective organizational standards must be established in order to strengthen the viability and legitimacy of professional services in demanding times.

Radiofrequency ablation of lung malignancies

Radiofrequency ablation is a new technology that has been used successfully to treat hepatic tumors. Recently, an increasing number of reports have described the use of radiofrequency ablation for primary and metastatic lung tumors. Although such early experience appears promising, many questions regarding patient selection, radiofrequency ablation technique, effectiveness of ablation on lung tumors, radiographic follow-up, and survival remain unanswered. This article addresses these issues and provides the thoracic surgeon with a current review of the application of radiofrequency ablation to lung tumors.