Thematic analysis of tools for health innovators and organisation leaders to develop digital health solutions fit for climate change

OBJECTIVES

While ethicists have largely underscored the risks raised by digital health solutions that operate with or without artificial intelligence (AI), limited research has addressed the need to also mitigate their environmental footprint and equip health innovators as well as organisation leaders to meet responsibility requirements that go beyond clinical safety, efficacy and ethics. Drawing on the Responsible Innovation in Health framework, this qualitative study asks: (1) what are the practice-oriented tools available for innovators to develop environmentally sustainable digital solutions and (2) how are organisation leaders supposed to support them in this endeavour?

METHODS

Focusing on a subset of 34 tools identified through a comprehensive scoping review (health sciences, computer sciences, engineering and social sciences), our qualitative thematic analysis identifies and illustrates how two responsibility principles-environmental sustainability and organisational responsibility-are meant to be put in practice.

RESULTS

Guidance to make environmentally sustainable digital solutions is found in 11 tools whereas organisational responsibility is described in 33 tools. The former tools focus on reducing energy and materials consumption as well as pollution and waste production. The latter tools highlight executive roles for data risk management, data ethics and AI ethics. Only four tools translate environmental sustainability issues into tangible organisational responsibilities.

CONCLUSIONS

Recognising that key design and development decisions in the digital health industry are largely shaped by market considerations, this study indicates that significant work lies ahead for medical and organisation leaders to support the development of solutions fit for climate change.

A Comprehensive, Valid, and Reliable Tool to Assess the Degree of Responsibility of Digital Health Solutions That Operate With or Without Artificial Intelligence: 3-Phase Mixed Methods Study

BACKGROUND

Clinicians' scope of responsibilities is being steadily transformed by digital health solutions that operate with or without artificial intelligence (DAI solutions). Most tools developed to foster ethical practices lack rigor and do not concurrently capture the health, social, economic, and environmental issues that such solutions raise.

OBJECTIVE

To support clinical leadership in this field, we aimed to develop a comprehensive, valid, and reliable tool that measures the responsibility of DAI solutions by adapting the multidimensional and already validated Responsible Innovation in Health Tool.

METHODS

We conducted a 3-phase mixed methods study. Relying on a scoping review of available tools, phase 1 (concept mapping) led to a preliminary version of the Responsible DAI solutions Assessment Tool. In phase 2, an international 2-round e-Delphi expert panel rated on a 5-level scale the importance, clarity, and appropriateness of the tool's components. In phase 3, a total of 2 raters independently applied the revised tool to a sample of DAI solutions (n=25), interrater reliability was measured, and final minor changes were made to the tool.

RESULTS

The mapping process identified a comprehensive set of responsibility premises, screening criteria, and assessment attributes specific to DAI solutions. e-Delphi experts critically assessed these new components and provided comments to increase content validity (n=293), and after round 2, consensus was reached on 85% (22/26) of the items surveyed. Interrater agreement was substantial for a subcriterion and almost perfect for all other criteria and assessment attributes.

CONCLUSIONS

The Responsible DAI solutions Assessment Tool offers a comprehensive, valid, and reliable means of assessing the degree of responsibility of DAI solutions in health. As regulation remains limited, this forward-looking tool has the potential to change practice toward more equitable as well as economically and environmentally sustainable digital health care.

How can entrepreneurs experience inform responsible health innovation policies? A longitudinal case study in Canada and Brazil

AIM

To foster equity and make health systems economically and environmentally more sustainable, Responsible Innovation in Health (RIH) calls for policy changes advocated by mission-oriented innovation policies. These policies focus, however, on instruments to foster the supply of innovations and neglect health policies that affect their uptake. Our study's aim is to inform policies that can support RIH by gaining insights into RIH-oriented entrepreneurs' experience with the policies that influence both the supply of, and the demand for their innovations.

METHODS

We recruited 16 for-profit and not-for-profit organisations engaged in the production of RIH in Brazil and Canada in a longitudinal multiple case study. Our dataset includes three rounds of interviews (n = 48), self-reported data, and fieldnotes. We performed qualitative thematic analyses to identify across-cases patterns.

FINDINGS

RIH-oriented entrepreneurs interact with supply side policies that support technology-led solutions because of their economic potential but that are misaligned with societal challenge-led solutions. They navigate demand side policies where market approval and physician incentives largely condition the uptake of technology-led solutions and where emerging policies bring some support to societal challenge-led solutions. Academic intermediaries that bridge supply and demand side policies may facilitate RIH, but our findings point to an overall lack of policy directionality that limits RIH.

CONCLUSION

As mission-oriented innovation policies aim to steer innovation towards the tackling of societal challenges, they call for a major shift in the public sector's role. A comprehensive mission-oriented policy approach to RIH requires policy instruments that can align, orchestrate, and reconcile health priorities with a renewed understanding of innovation-led economic development.

An urgent call for the environmental sustainability of health systems: A 'sextuple aim' to care for patients, costs, providers, population equity and the planet

Health systems have a duty to protect the health and well-being of individuals and populations. Yet, healthcare contributes about 4.6% of global greenhouse gas emissions. Health systems need to question and improve established practices, assume strong environmental leadership, and aim for ambitious, sometimes radical, actions in favour of the climate. In this paper, we interrogate the suitability and feasibility of integrating the aim of 'environmental sustainability' to form the 'Sextuple Aim.' Environmental sustainability may be in tension with, but also a potential lever to meet the other cardinal aims: (1) quality and experience of patient care; (2) population health; (3) quality of work and satisfaction of healthcare providers; (4) equity and inclusion; and (5) cost reduction. We propose policy and practical avenues to help move towards the Sextuple Aim.

Tools to foster responsibility in digital solutions that operate with or without artificial intelligence: A scoping review for health and innovation policymakers

BACKGROUND

Digital health solutions that operate with or without artificial intelligence (D/AI) raise several responsibility challenges. Though many frameworks and tools have been developed, determining what principles should be translated into practice remains under debate. This scoping review aims to provide policymakers with a rigorous body of knowledge by asking: 1) what kinds of practice-oriented tools are available?; 2) on what principles do they predominantly rely?; and 3) what are their limitations?

METHODS

We searched six academic and three grey literature databases for practice-oriented tools, defined as frameworks and/or sets of principles with clear operational explanations, published in English or French from 2015 to 2021. Characteristics of the tools were qualitatively coded and variations across the dataset identified through descriptive statistics and a network analysis.

FINDINGS

A total of 56 tools met our inclusion criteria: 19 health-specific tools (33.9%) and 37 generic tools (66.1%). They adopt a normative (57.1%), reflective (35.7%), operational (3.6%), or mixed approach (3.6%) to guide developers (14.3%), managers (16.1%), end users (10.7%), policymakers (5.4%) or multiple groups (53.6%). The frequency of 40 principles varies greatly across tools (from 0% for 'environmental sustainability' to 83.8% for 'transparency'). While 50% or more of the generic tools promote up to 19 principles, 50% or more of the health-specific tools promote 10 principles, and 50% or more of all tools disregard 21 principles. In contrast to the scattered network of principles proposed by academia, the business sector emphasizes closely connected principles. Few tools rely on a formal methodology (17.9%).

CONCLUSION

Despite a lack of consensus, there is a solid knowledge-basis for policymakers to anchor their role in such a dynamic field. Because several tools lack rigour and ignore key social, economic, and environmental issues, an integrated and methodologically sound approach to responsibility in D/AI solutions is warranted.

Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This "perspective" paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations' access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the "solution to everything". In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial "Direct-To-Consumer" services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to "capabilities" supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing "public health value" through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

Responsible innovation in health and health system sustainability: Insights from health innovators' views and practices

Although healthcare managers make increasingly difficult decisions about health innovations, the way they may interact with innovators to foster health system sustainability remains underexplored. Drawing on the Responsible Innovation in Health (RIH) framework, this paper analyses interviews (n=37) with Canadian and Brazilian innovators to identify: how they operationalize inclusive design processes; what influences the responsiveness of their innovation to system-level challenges; and how they consider the level and intensity of care required by their innovation. Our qualitative findings indicate that innovators seek to: 1) engage stakeholders at an early ideation stage through context-specific methods combining both formal and informal strategies; 2) address specific system-level benefits but often struggle with the positioning of their solution within the health system; and 3) mitigate staff shortages in specialized care, increase general practitioners’ capacity or patients and informal caregivers’ autonomy. These findings provide empirical insights on how healthcare managers can promote and organize collaborative processes that harness innovation towards more sustainable health systems. By adopting a RIH-oriented managerial role, they can set in place more inclusive design processes, articulate key system-level challenges, and help innovators adjust the level and intensity of care required by their innovation.

A “Not So Quiet” Revolution: Systemic Benefits and Challenges of Telehealth in the Context of COVID-19 in Quebec (Canada)

The COVID-19 pandemic has had a major impact on health and social service systems (HSSS) worldwide. It has put tremendous pressure on these systems, threatening access, continuity, and the quality of patient care and services. In Quebec (Canada), the delivery of care and services has radically changed in a short period of time. During the pandemic, telehealth has been widely deployed and used, notwithstanding the decades-long challenges of integrating this service modality into the Quebec HSSS. Adopting a narrative-integrative approach, this article describes and discusses Quebec's experience with the deployment and utilization of telehealth in the context of COVID-19. Firstly, we introduced the achievements and benefits made with the use of telehealth. Secondly, we discussed the challenges and concerns that were revealed or accentuated by the sanitary crisis, such as: (1) training and information; (2) professional and organizational issues; (3) quality of services and patient satisfaction; (4) cost, remuneration, and funding; (5) technology and infrastructure; (6) the emergence of private telehealth platforms in a public HSSS; (7) digital divide and equity; and (8) legal and regulatory issues. Finally, the article presents recommendations to guide future research, policies and actions for a successful integration of telehealth in the Quebec HSSS as well as in jurisdictions and countries facing comparable challenges.

Organizational readiness for artificial intelligence in health care: insights for decision-making and practice

PURPOSE

Artificial intelligence (AI) raises many expectations regarding its ability to profoundly transform health care delivery. There is an abundant literature on the technical performance of AI applications in many clinical fields (e.g. radiology, ophthalmology). This article aims to bring forward the importance of studying organizational readiness to integrate AI into health care delivery.

DESIGN/METHODOLOGY/APPROACH

The reflection is based on our experience in digital health technologies, diffusion of innovations and healthcare organizations and systems. It provides insights into why and how organizational readiness should be carefully considered.

FINDINGS

As an important step to ensure successful integration of AI and avoid unnecessary investments and costly failures, better consideration should be given to: (1) Needs and added-value assessment; (2) Workplace readiness: stakeholder acceptance and engagement; (3) Technology-organization alignment assessment and (4) Business plan: financing and investments. In summary, decision-makers and technology promoters should better address the complexity of AI and understand the systemic challenges raised by its implementation in healthcare organizations and systems.

ORIGINALITY/VALUE

Few studies have focused on the organizational issues raised by the integration of AI into clinical routine. The current context is marked by a perplexing gap between the willingness of decision-makers and technology promoters to capitalize on AI applications to improve health care delivery and the reality on the ground, where it is difficult to initiate the changes needed to realize their full benefits while avoiding their negative impacts.

How Can Health Systems Better Prepare for the Next Pandemic? Lessons Learned From the Management of COVID-19 in Quebec (Canada)

The magnitude of the COVID-19 pandemic challenged societies around our globalized world. To contain the spread of the virus, unprecedented and drastic measures and policies were put in place by governments to manage an exceptional health care situation while maintaining other essential services. The responses of many governments showed a lack of preparedness to face this systemic and global health crisis. Drawing on field observations and available data on the first wave of the pandemic (mid-March to mid-May 2020) in Quebec (Canada), this article reviewed and discussed the successes and failures that characterized the management of COVID-19 in this province. Using the framework of Palagyi et al. on system preparedness toward emerging infectious diseases, we described and analyzed in a chronologically and narratively way: (1) how surveillance was structured; (2) how workforce issues were managed; (3) what infrastructures and medical supplies were made available; (4) what communication mechanisms were put in place; (5) what form of governance emerged; and (6) whether trust was established and maintained throughout the crisis. Our findings and observations stress that resilience and ability to adequately respond to a systemic and global crisis depend upon preexisting system-level characteristics and capacities at both the provincial and federal governance levels. By providing recommendations for policy and practice from a learning health system perspective, this paper contributes to the groundwork required for interdisciplinary research and genuine policy discussions to help health systems better prepare for future pandemics.

Fostering Responsible Innovation in Health: An Evidence-Informed Assessment Tool for Innovation Stakeholders

BACKGROUND

Responsible innovation in health (RIH) emphasizes the importance of developing technologies that are responsive to system-level challenges and support equitable and sustainable healthcare. To help decision-makers identify whether an innovation fulfills RIH requirements, we developed and validated an evidence-informed assessment tool comprised of 4 inclusion and exclusion criteria, 9 assessment attributes and a scoring system.

METHODS

We conducted an inter-rater reliability assessment to establish the extent to which 2 raters agree when applying the RIH Tool to a diversified sample of health innovations (n=25). Following the Tool's 3-step process, sources of information were collected and cross-checked to ensure their clarity and relevance. Ratings were reported independently in a spreadsheet to generate the study's database. To measure inter-rater reliability, we used: a non-adjusted index (percent agreement), a chance-adjusted index (Gwet's AC) and the Pearson's correlation coefficient. Results of the Tool's application to the whole sample of innovations are summarized through descriptive statistics.

RESULTS

Our findings show complete agreement for the screening criteria, "almost perfect" agreement for 7 assessment attributes, "substantial" agreement for 2 attributes and "almost perfect" agreement for the RIH overall score. A large portion of the sample obtained high scores for 6 attributes (health relevance, health inequalities, responsiveness, level and intensity of care and frugality) and low scores for 3 attributes (ethical, legal, and social issues [ELSIs], inclusiveness and eco-responsibility). At the rating step, 88% of the innovations had a sufficient number of attributes documented (≥ 7/9), but the assessment was based on sources of moderate to high quality (mean score ≥ 2 points) for 36% of the sample. While "Almost all RIH features" were present for 24% of the innovations (RIH mean score between 4.1-5.0 points), "Many RIH features" were present for 52% of the sample (3.1-4.0 points) and "Few RIH features" were present for 24% of the innovations (2.1-3.0 points).

CONCLUSION

By confirming key aspects of the RIH Tool's reliability and applicability, our study brings its development to completion. It can be jointly put into action by innovation stakeholders who want to foster innovations with greater social, economic and environmental value.

"It's not just hacking for the sake of it": a qualitative study of health innovators' views on patient-driven open innovations, quality and safety

BACKGROUND

Open do-it-yourself (DIY) health innovations raise new dilemmas for patient-oriented and service-oriented scholars and healthcare providers. Our study aimed to generate practical insights into quality and safety issues to patient care raised by two volunteer-run, open DIY solutions: Nightscout Project (patient-driven, open-source software for type 1 diabetes management) and e-NABLE (volunteers who design and three-dimensionally print upper-limb assistive devices). To this end, we examined the views of health innovators who are knowledgeable about medical devices standards and regulations.

METHODS

We applied a multimedia-based, data-elicitation technique to conduct indepth interviews with a diversified sample of 31 health innovators practising in two Canadian provinces (Quebec and Ontario). An exploratory thematic analysis approach was used to identify respondents' reasoning processes and compare their overall judgements of Nightscout and e-NABLE.

RESULTS

Respondents pondered the following quality and safety issues: importance of the need addressed; accessibility; volunteers' ability to develop and maintain a safe solution of good quality; risks involved for users; consequences of not using the solution; and liability. Overall, innovators see Nightscout as a high-risk DIY solution that requires expert involvement and e-NABLE as a low-risk one that fills a hard-to-meet gap.

CONCLUSION

Health innovators generally support patient-driven initiatives but also call for the involvement of professionals who possess complementary skills and knowledge. Our findings provide a list of issues healthcare providers may discuss with patients during clinical consultations to document potential risks and benefits of open DIY solutions. To inform new policy approaches, we propose the development of publicly funded umbrella organisations to act as intermediaries between open DIY solutions and regulatory bodies to help them meet quality and safety standards.

Guiding Pay-As-You-Live Health Insurance Models Toward Responsible Innovation in Health

While the transition toward digitalized health care and service delivery challenges many publicly and privately funded health systems, patients are already producing a phenomenal amount of data on their health and lifestyle through their personal use of mobile technologies. To extract value from such user-generated data, a new insurance model is emerging called Pay-As-You-Live (PAYL). This model differs from other insurance models by offering to support clients in the management of their health in a more interactive yet directive manner. Despite significant promises for clients, there are critical issues that remain unaddressed, especially as PAYL models can significantly disrupt current collective insurance models and question the social contract in so-called universal and public health systems. In this paper, we discuss the following issues of concern: the quantification of health-related behavior, the burden of proof of compliance, client data privacy, and the potential threat to health insurance models based on risk mutualization. We explore how more responsible health insurance models in the digital health era could be developed, particularly by drawing from the Responsible Innovation in Health framework.

Artificial Intelligence and Health Technology Assessment: Anticipating a New Level of Complexity

Artificial intelligence (AI) is seen as a strategic lever to improve access, quality, and efficiency of care and services and to build learning and value-based health systems. Many studies have examined the technical performance of AI within an experimental context. These studies provide limited insights into the issues that its use in a real-world context of care and services raises. To help decision makers address these issues in a systemic and holistic manner, this viewpoint paper relies on the health technology assessment core model to contrast the expectations of the health sector toward the use of AI with the risks that should be mitigated for its responsible deployment. The analysis adopts the perspective of payers (ie, health system organizations and agencies) because of their central role in regulating, financing, and reimbursing novel technologies. This paper suggests that AI-based systems should be seen as a health system transformation lever, rather than a discrete set of technological devices. Their use could bring significant changes and impacts at several levels: technological, clinical, human and cognitive (patient and clinician), professional and organizational, economic, legal, and ethical. The assessment of AI's value proposition should thus go beyond technical performance and cost logic by performing a holistic analysis of its value in a real-world context of care and services. To guide AI development, generate knowledge, and draw lessons that can be translated into action, the right political, regulatory, organizational, clinical, and technological conditions for innovation should be created as a first step.

Transforming Disciplinary Traditions Comment on "Problems and Promises of Health Technologies: The Role of Early Health Economic Modeling"

Grutters et al show that economic assessments can inform the development of new health technologies at an early stage. This is an important contribution to health services and policy research, which implies a "shift away" from the more traditional forms of academic health economic modeling. Because transforming established disciplinary traditions is both valuable and demanding, we invite scholars to further the discussion on how the value of health innovations should be appraised in view of today’s societal challenges.

Artificial intelligence in health care: laying the Foundation for Responsible, sustainable, and inclusive innovation in low- and middle-income countries

The World Health Organization and other institutions are considering Artificial Intelligence (AI) as a technology that can potentially address some health system gaps, especially the reduction of global health inequalities in low- and middle-income countries (LMICs). However, because most AI-based health applications are developed and implemented in high-income countries, their use in LMICs contexts is recent and there is a lack of robust local evaluations to guide decision-making in low-resource settings. After discussing the potential benefits as well as the risks and challenges raised by AI-based health care, we propose five building blocks to guide the development and implementation of more responsible, sustainable, and inclusive AI health care technologies in LMICs.

Rethinking the electronic health record through the quadruple aim: time to align its value with the health system

Electronic health records (EHRs) are considered as a powerful lever for enabling value-based health systems. However, many challenges to their use persist and some of their unintended negative impacts are increasingly well documented, including the deterioration of work conditions and quality, and increased dissatisfaction of health care providers. The “quadruple aim” consists of improving population health as well as patient and provider experience while reducing costs. Based on this approach, improving the quality of work and well-being of health care providers could help rethinking the implementation of EHRs and also other information technology-based tools and systems, while creating more value for patients, organizations and health systems.

Deliberating as a Public Representative or as a Potential User? Two Complementary Perspectives that Should Inform Health Innovation Policy

While public involvement in health policy is gaining traction around the world, deciding whether practitioners of public involvement should encourage participants to deliberate from a personal or a collective perspective remains an object of contention. Drawing on an empirical study, the aim of this article is to generate methodological insights into these two perspectives. Our qualitative analyses illustrate how members of the public contributed differently to deliberations about the value of health innovations by alternatively sharing views as public representatives and as potential users. When engaging as public representatives, participants raised important collective concerns, and, when engaging as potential users, participants brought concrete details and contextual nuances to the group exchanges. Because these perspectives entail different yet mutually challenging ways of appraising health innovations, public engagement practitioners should foster both personal and collective perspectives.

Information needs of francophone health care professionals and the public with regard to medical assistance in dying in Quebec: a qualitative study

BACKGROUND

In 2016, the Canadian government legalized medical assistance in dying (MAiD) for adults with terminal illness. The objective of this study was to explore the information needs of health care professionals and members of the public regarding MAiD.

METHODS

This was a qualitative study involving a 1-day face-to-face forum followed by a 3-week online forum across the province of Quebec conducted in June 2016. French-speaking participants targeted for the study included members of the public (citizens, patients and caregivers) and health care professionals. Participants were recruited through calls for applications to a patient partner network and via social media, and through mailing lists of partner professional and community organizations across Quebec. We used a purposeful sampling strategy to recruit a diverse group of participants. In the forums, deliberations were prompted by short informational videos about MAiD. We performed a thematic analysis to identify key information needs.

RESULTS

Fifty members of the public and 35 health care professionals participated. Forty-three people participated in the face-to-face meeting, and 42 people participated online. Participants identified 32 information needs (22 expressed by both members of the public and health care professionals, and 10 specific to members of the public) regarding the definition of MAiD, eligibility criteria, and documenting and evaluating practices. Information needs varied along different stages of the patient's journey. Participants expressed the need to be informed about issues that go beyond the medical and legal aspects of MAiD (e.g., relational, symbolic, psychological and spiritual aspects).

INTERPRETATION

The findings show that health care professionals and members of the public have common information needs regarding MAiD and seek information on the relational, emotional and symbolic aspects of this practice. These findings call for concerted efforts to build a common information base - covering dimensions that go beyond the medical and legal aspects of MAiD - to facilitate informed conversations among patients, health care professionals and members of the public.

What Health System Challenges Should Responsible Innovation in Health Address? Insights From an International Scoping Review

Background: While responsible innovation in health (RIH) suggests that health innovations could be purposefully designed to better support health systems, little is known about the system-level challenges that it should address. The goal of this paper is thus to document what is known about health systems’ demand for innovations.

Methods: We searched 8 databases to perform a scoping review of the scientific literature on health system challenges published between January 2000 and April 2016. The challenges reported in the articles were classified using the dynamic health system framework. The countries where the studies had been conducted were grouped using the human development index (HDI). Frequency distributions and qualitative content analysis were performed.

Results: Up to 1391 challenges were extracted from 254 articles examining health systems in 99 countries. Across countries, the most frequently reported challenges pertained to: service delivery (25%), human resources (23%), and leadership and governance (21%). Our analyses indicate that innovations tend to increase challenges associated to human resources by affecting the nature and scope of their tasks, skills and responsibilities, to exacerbate service delivery issues when they are meant to be used by highly skilled providers and call for accountable governance of their dissemination, use and reimbursement. In countries with a low and medium HDI, problems arising with infrastructure, logistics and equipment were described in connection with challenges affecting procurement, supply and distribution systems. In countries with a medium and high HDI, challenges included a growing demand for drugs and new technology and the management of rising costs. Across all HDI groups, the need for flexible information technologies (IT) solutions to reach rural areas was underscored.

Conclusion: Highlighting challenges that are common across countries, this study suggests that RIH should aim to reduce the cost of innovation production processes and attend not only to the requirements of the immediate clinical context of use, but also to the vulnerabilities of the broader system wherein innovations are deployed. Policy-makers should translate system-level demand signals into innovation development opportunities since it is imperative to foster innovations that contribute to the success and sustainability of health systems

Introducing responsible innovation in health: a policy-oriented framework

The scholarship on responsible research and innovation (RRI) aims to align the processes and outcomes of innovation with societal values by involving a broad range of stakeholders from a very early stage. Though this scholarship offers a new lens to consider the challenges new health technologies raise for health systems around the world, there is a need to define the dimensions that specifically characterise responsible innovation in health (RIH). The present article aims to introduce an integrative RIH framework drawing on the RRI literature, the international literature on health systems as well as specific bodies of knowledge that shed light on key dimensions of health innovations. Combining inductive and deductive theory-building strategies and concomitant with the development of a formal tool to assess the responsibility of innovations, we developed a framework that is comprised of nine dimensions organised within five value domains, namely population health, health system, economic, organisational and environmental. RIH provides health and innovation policy-makers with a common framework that supports the development of innovations that can tackle significant system-level challenges, including sustainability and equity.

Patient and public engagement in research and health system decision making: A systematic review of evaluation tools

BACKGROUND

Patient and public engagement is growing, but evaluative efforts remain limited. Reviews looking at evaluation tools for patient engagement in individual decision making do exist, but no similar articles in research and health systems have been published.

OBJECTIVE

Systematically review and appraise evaluation tools for patient and public engagement in research and health system decision making.

METHODS

We searched literature published between January 1980 and February 2016. Electronic databases (Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL and PsycINFO) were consulted, as well as grey literature obtained through Google, subject-matter experts, social media and engagement organization websites. Two independent reviewers appraised the evaluation tools based on 4 assessment criteria: scientific rigour, patient and public perspective, comprehensiveness and usability.

RESULTS

In total, 10 663 unique references were identified, 27 were included. Most of these tools were developed in the last decade and were designed to support improvement of engagement activities. Only 11% of tools were explicitly based on a literature review, and just 7% were tested for reliability. Patients and members of the public were involved in designing 56% of the tools, mainly in the piloting stage, and 18.5% of tools were designed to report evaluation results to patients and the public.

CONCLUSION

A growing number of evaluation tools are available to support patient and public engagement in research and health system decision making. However, the scientific rigour with which such evaluation tools are developed could be improved, as well as the level of patient and public engagement in their design and reporting.

When robots care: Public deliberations on how technology and humans may support independent living for older adults

While assistive robots receive growing attention as a potential solution to support older adults to live independently, several scholars question the underlying social, ethical and health policy assumptions. One perplexing issue is determining whether assistive robots should be introduced to supplement caregivers or substitute them. Current state of knowledge indicates that users and caregivers consider that robots should not aim to replace humans, but could perform certain tasks. This begs the question of the nature and scope of the tasks that can be delegated to robots and of those that should remain under human responsibility. Considering that such tasks entail a range of actions that affect the meaning of caregiving and care receiving, this article offers sociological insights into the ways in which members of the public reason around assistive actions, be they performed by humans, machines or both. Drawing on a prospective public deliberation study that took place in Quebec (Canada) in 2014 with participants (n = 63) of different age groups, our findings clarify how they envisage what robots can and cannot do to assist older people, and when and why delegating certain tasks to robots becomes problematic. A better understanding of where the publics draw a limit in the substitution of humans by robots refocuses policymakers' attention on what good care entails in modern healthcare systems.

The institutional workers of biomedical science: Legitimizing academic entrepreneurship and obscuring conflicts of interest

Given growing initiatives incentivizing academic researchers to engage in 'entrepreneurial' activities, this article examines how these academic entrepreneurs claim value in their entrepreneurial engagements, and navigate concerns related to conflicts of interest. Using data from qualitative interviews with twenty-four academic entrepreneurs in Canada, we show how these scientists value entrepreneurial activities for providing financial and intellectual resources to academic science, as well as for their potential to create impact through translation. Simultaneously, these scientists claimed to maintain academic norms of disinterested science and avoid conflicts of interest. Using theories of institutional work, we demonstrate how entrepreneurial scientists engage in processes of institutional change-through-maintenance, drawing on the maintenance of academic norms as institutional resources to legitimize entrepreneurial activities. As entrepreneurial scientists work to legitimize new zones of academic scientific practice, there is a need to carefully regulate and scrutinize these activities so that their potential harms do not become obscured.

Anticipating health innovations in 2030-2040: Where does responsibility lie for the publics?

Considering that public engagement is pivotal to the mission of Responsible Research and Innovation, this article's aim is to examine how members of the public conceive of the relationship between responsibility and prospective health technologies. We organized four face-to-face deliberative workshops and an online forum wherein participants were invited to comment on scenarios involving three fictional technologies in 2030 and 2040. Our analyses describe how participants anticipated these technologies' impacts and formulated two conditions for their use: they should (1) be embedded within professional care and services and (2) include social protection of individual freedom and privacy. By clarifying what technological direction shall be avoided and who shall act responsibly, these conditions emphasize our participants' understanding of society as much as their understanding of science. For new technologies to be deployed in socially responsible ways, public engagement methods should be developed alongside public governance and regulatory strategies.

Teleconsultation: Rejected and Emerging Uses

Objective: The aim of this paper is to analyse telemedicine as a new means to improve health care accessibility.

Method: A case study design was used to understand how medical specialists perceived, made sense of, and appropriated a teleconsultation system.

Results and Conclusions: The technology was used neither in the manner nor to the extent anticipated by its designers. A fundamental modification to the traditional medical consultation process has emerged. Unable to be used as a substitute to the traditional medical consultation process, the teleconsultation system imposes a greater burden on the shoulders of participating physicians who, after a few trials, returned to their traditional mode of practice.

Multiple constraints compromise decision-making about implantable medical devices for individual patients: qualitative interviews with physicians

Background

Little research has examined how physicians choose medical devices for treating individual patients to reveal if interventions are needed to support decision-making and reduce device-associated morbidity and mortality. This study explored factors that influence choice of implantable device from among available options.

Methods

A descriptive qualitative approach was used. Physicians who implant orthopedic and cardiovascular devices were identified in publicly available directories and web sites. They were asked how they decided what device to use in a given patient, sources of information they consulted, and how patients were engaged in decision-making. Sampling was concurrent with data collection and analysis to achieve thematic saturation. Data were analyzed using constant comparative technique by all members of the research team.

Results

Twenty-two physicians from five Canadian provinces (10 cardiovascular, 12 orthopedic; 8, 10 and 4 early, mid and late career, respectively) were interviewed. Responses did not differ by specialty, geographic region or career stage. Five major categories of themes emerged that all influence decision-making about a range of devices, and often compromise choice of the most suitable device for a given patient, potentially leading to sub-optimal clinical outcomes: lack of evidence on device performance, patient factors, physician factors, organizational and health system factors, and device and device market factors. In the absence of evidence from research or device registries, tacit knowledge from trusted colleagues and less-trusted industry representatives informed device choice. Patients were rarely engaged in decision-making. Physician preference for particular devices was a barrier to acquiring competency in devices potentially more suitable for patients. Access to suitable devices was further limited to the number of comparable devices on the market, local inventory and purchasing contract specifications.

Conclusions

This study revealed that decision-making about devices is complex, cognitively challenging and constrained by several factors limiting access to and use of devices that could optimize patient outcomes. Further research is needed to assess the impact of these constraints on clinical outcomes, and develop interventions that optimize decision-making about device choice for treating given patients.

Electronic supplementary material

The online version of this article (10.1186/s12911-017-0577-3) contains supplementary material, which is available to authorized users.

Factors constraining patient engagement in implantable medical device discussions and decisions: interviews with physicians

Objective

Patient engagement (PE) is warranted when treatment risks and outcomes are uncertain, as is the case for higher risk medical devices. Previous research found that patients were not engaged in discussions or decisions about implantable medical devices. This study explored physician views about engaging patients in such discussions.

Design

Qualitative interviews using a basic descriptive approach.

Setting

Canada.

Participants

Practicing cardiovascular and orthopaedic physicians.

Main outcome measures

Level, processes and determinants of PE in medical device discussions and decisions.

Results

Views were largely similar among 10 cardiovascular and 12 orthopaedic physicians interviewed. Most said that it was feasible to inform and sometimes involve patients in discussions, but not to partner with them in medical device decision-making. PE was constrained by patient (comfort with PE, technical understanding, physiologic/demographic characteristics, prognosis), physician (device preferences, time), health system (purchasing contracts) and device factors (number of devices on market, comparative advantage). A framework was generated to help physicians engage patients in discussions about medical devices, even when decisions may not be preference sensitive due to multiple constraints on choice.

Conclusions

This study identified that patients are not engaged in discussions or decisions about implantable medical devices. This may be due to multiple constraints. Further research should establish the legitimacy, prevalence and impact of constraining factors, and examine whether and how different levels and forms of PE are needed and feasible.

What do we know about the needs and challenges of health systems? A scoping review of the international literature

Background

While there is an extensive literature on Health System (HS) strengthening and on the performance of specific HSs, there are few exhaustive syntheses of the challenges HSs are facing worldwide. This paper reports the findings of a scoping review aiming to classify the challenges of HSs investigated in the scientific literature. Specifically, it determines the kind of research conducted on HS challenges, where it was performed, in which health sectors and on which populations. It also identifies the types of challenge described the most and how they varied across countries.

Methods

We searched 8 databases to identify scientific papers published in English, French and Italian between January 2000 and April 2016 that addressed HS needs and challenges. The challenges reported in the articles were classified using van Olmen et al.’s dynamic HS framework. Countries were classified using the Human Development Index (HDI). Our analyses relied on descriptive statistics and qualitative content analysis.

Results

292 articles were included in our scoping review. 33.6% of these articles were empirical studies and 60.1% were specific to countries falling within the very high HDI category, in particular the United States. The most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%). The most frequently studied target populations included elderly people (23%), people living in remote or poor areas (21%), visible or ethnic minorities (15%), and children and adolescents (15%). The most frequently reported challenges related to human resources (22%), leadership and governance (21%) and health service delivery (24%). While health service delivery challenges were more often examined in countries within the very high HDI category, human resources challenges attracted more attention within the low HDI category.

Conclusions

This scoping review provides a quantitative description of the available evidence on HS challenges and a qualitative exploration of the dynamic relationships that HS components entertain. While health services research is increasingly concerned about the way HSs can adopt innovations, little is known about the system-level challenges that innovations should address in the first place. Within this perspective, four key lessons are drawn as well as three knowledge gaps.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2585-5) contains supplementary material, which is available to authorized users.

Providing Value to New Health Technology: The Early Contribution of Entrepreneurs, Investors, and Regulatory Agencies

Background: New technologies constitute an important cost-driver in healthcare, but the dynamics that lead to their emergence remains poorly understood from a health policy standpoint. The goal of this paper is to clarify how entrepreneurs, investors, and regulatory agencies influence the value of emerging health technologies.

Methods: Our 5-year qualitative research program examined the processes through which new health technologies were envisioned, financed, developed and commercialized by entrepreneurial clinical teams operating in Quebec’s (Canada) publicly funded healthcare system.

Results: Entrepreneurs have a direct influence over a new technology’s value proposition, but investors actively transform this value. Investors support a technology that can find a market, no matter its intrinsic value for clinical practice or healthcare systems. Regulatory agencies reinforce the "double" value of a new technology—as a health intervention and as an economic commodity—and provide economic worth to the venture that is bringing the technology to market.

Conclusion: Policy-oriented initiatives such as early health technology assessment (HTA) and coverage with evidence may provide technology developers with useful input regarding the decisions they make at an early stage. But to foster technologies that bring more value to healthcare systems, policy-makers must actively support the consideration of health policy issues in innovation policy.

Factors influencing the reporting of adverse medical device events: qualitative interviews with physicians about higher risk implantable devices

BACKGROUND

Postmarket surveillance of medical devices is reliant on physician reporting of adverse medical device events (AMDEs). Little is known about factors that influence whether and how physicians report AMDEs, an essential step in developing behaviour change interventions. This study explored factors that influence AMDE reporting.

METHODS

Qualitative interviews were conducted with physicians who differed by specialties that implant cardiovascular and orthopaedic devices prone to AMDEs, geography and years in practice. Participants were asked if and how they reported AMDEs, and the influencing factors. Themes were identified inductively using constant comparative technique, and reviewed and discussed by the research team on four occasions.

RESULTS

Twenty-two physicians of varying specialty, region, organisation and career stage perceived AMDE reporting as unnecessary, not possible or futile due to multiple factors. Physicians viewed AMDEs as an expected part of practice that they could manage by switching to different devices or developing work-around strategies for problematic devices. Physician beliefs and behaviour were reinforced by limited healthcare system capacity and industry responsiveness. The healthcare system lacked processes and infrastructure to detect, capture, share and act on information about AMDEs, and constrained device choice through purchasing contracts. The device industry did not respond to reports of AMDEs from physicians or improve their products based on such reports. As a result, participants said they used devices that were less than ideal for a given patient, leading to suboptimal patient outcomes.

CONCLUSIONS

There may be little point in solely educating or incentivising individual physicians to report AMDEs unless environmental conditions are conducive to doing so. Future research should explore policies that govern AMDEs and investigate how to design and implement postmarket surveillance systems.

"We can't get along without each other": Qualitative interviews with physicians about device industry representatives, conflict of interest and patient safety

Objectives

Physician relationships with device industry representatives have not been previously assessed. This study explored interactions with device industry representatives among physicians who use implantable cardiovascular and orthopedic devices to identify whether conflict of interest (COI) is a concern and how it is managed.

Design

A descriptive qualitative approach was used. Physicians who implant orthopedic and cardiovascular devices were identified in publicly available directories and web sites, and interviewed about their relationships with device industry representatives. Sampling was concurrent with data collection and analysis. Data were analyzed and discussed using constant comparative technique by all members of the research team.

Results

Twenty-two physicians (10 cardiovascular, 12 orthopedic) were interviewed. Ten distinct representative roles were identified: purchasing, training, trouble-shooting, supplying devices, assisting with device assembly and insertion, supporting operating room staff, mitigating liability, conveying information about recalls, and providing direct and indirect financial support. Participants recognized the potential for COI but representatives were present for the majority of implantations. Participants revealed a tension between physicians and representatives that was characterized as “symbiotic”, but required physicians to be vigilant about COI and patient safety, particularly because representatives varied regarding disclosure of device defects. They described a concurrent tension between hospitals, whose policies and business practices were focused on cost-control, and physicians who were required to comply with those policies and use particular devices despite concerns about their safety and effectiveness.

Conclusions

Given the potential for COI and threats to patient safety, further research is needed to establish the clinical implications of the role of, and relationship with device industry representatives; and whether and how hospitals do and should govern interaction with representatives, or support their staff in this regard.

Creating a new articulation between research and practice through policy? The views and experiences of researchers and practitioners

OBJECTIVES

In 1990, the Quebec Social Research Council - a body financing social research in Quebec, Canada - launched a new policy encouraging the development of social research units within health care organizations. Through financial incentives, it encouraged the implementation of long-term collaborations between researchers and practitioners with the purpose of transforming both scientific knowledge production and professional practices. This paper examines the perceptions of researchers and practitioners regarding the attributes and the usefulness of this collaborative research policy.

METHODS

A self-administered survey was sent to all the researchers (n = 146; response rate 78.1%) and practitioners (n = 204; response rate 44.1%) involved in the 21 collaborative research teams funded in 1998. T-tests were performed in order to assess the difference between the perceptions of researchers and practitioners in five key dimensions of collaborative research.

RESULTS

The results showed that, contrary to expectations, researchers and practitioners shared fairly similar views regarding the various dimensions of collaborative research. They both agreed that their involvement within collaborative research teams had contributed to the development of new skills and practices but had not facilitated their participation in external activities nor their involvement in networks and organizations that influence environments in which public policies and practices are deployed. They also both encountered some difficulties in putting the dimensions that they highly valued into practice.

CONCLUSIONS

Collaborative research within health care organizations succeeded in fostering the implementation of new modes of knowledge production and intervention. Nevertheless, special attention needs to be given to the development of strategies to reduce the discrepancies between values and practices.

Medical innovation and the sustainability of health systems: A historical perspective on technological change in health

New medical technology challenges the sustainability of healthcare systems in several countries. Drawing on secondary sources of data, the aim of this article is to generate a better understanding of the historical Research & Development dynamics that have contributed to shape today’s medical innovation ecosystem. We describe key technological achievements along three historical periods – the 1950s, the 1980s and the 2000s – and situate them within their broader political, social, cultural and economic contexts. Our analyses bring forward self-reinforcing dynamics between technology, medical specialization, individualization of disease and the concentration of resources in academic teaching centres. We argue that the way medical innovation has been financed, designed and commercialized since the 1950s has engendered path dependency, which exacerbates the sustainability challenges healthcare systems are now facing. We conclude on the need for innovation design principles that could protect the sustainability of healthcare systems.

Assessment of a multimedia-based prospective method to support public deliberations on health technology design: participant survey findings and qualitative insights

Background

Using a combination of videos and online short stories, we conducted four face-to-face deliberative workshops in Montreal (Quebec, Canada) with members of the public who later joined additional participants in an online forum to discuss the social and ethical implications of prospective technologies. This paper presents the participants’ appraisal of our intervention and provides novel qualitative insights into the use of videos and online tools in public deliberations.

Methods

We applied a mixed-method study design. A self-administered survey contained open- and close-ended items using a 5-level Likert-like scale. Absolute frequencies and proportions for the close-ended items were compiled. Qualitative data included field notes, the transcripts of the workshops and the participants’ contributions to the online forum. The qualitative data were used to flesh out the survey data describing the participants’ appraisal of: 1) the multimedia components of our intervention; 2) its deliberative face-to-face and online processes; and 3) its perceived effects.

Results

Thirty-eight participants contributed to the workshops and 57 to the online forum. A total of 46 participants filled-in the survey, for a response rate of 73 % (46/63). The videos helped 96 % of the participants to understand the fictional technologies and the online scenarios helped 98 % to reflect about the issues raised. Up to 81 % considered the arguments of the other participants to be well thought-out. Nearly all participants felt comfortable sharing their ideas in both the face-to-face (89 %) and online environments (93 %), but 88 % preferred the face-to-face workshop. As a result of the intervention, 85 % reflected more about the pros and cons of technology and 94 % learned more about the way technologies may transform society.

Conclusions

This study confirms the methodological feasibility of a deliberative intervention whose originality lies in its use of videos and online scenarios. To increase deliberative depth and foster a strong engagement by all participants, face-to-face and online components need to be well integrated. Our findings suggest that online tools should be designed by considering, one the one hand, the participants’ self-perceived ability to share written comments and, on the other hand, the ease with which other participants can respond to such contributions.

International changes in end-of-life practices over time: a systematic review

Background

End-of-life policies are hotly debated in many countries, with international evidence frequently used to support or oppose legal reforms. Existing reviews are limited by their focus on specific practices or selected jurisdictions. The objective is to review international time trends in end-of-life practices.

Methods

We conducted a systematic review of empirical studies on medical end-of-life practices, including treatment withdrawal, the use of drugs for symptom management, and the intentional use of lethal drugs. A search strategy was conducted in MEDLINE, EMBASE, Web of Science, Sociological Abstracts, PAIS International, Worldwide Political Science Abstracts, International Bibliography of the Social Sciences and CINAHL. We included studies that described physicians’ actual practices and estimated annual frequency at the jurisdictional level. End-of-life practice frequencies were analyzed for variations over time, using logit regression.

Results

Among 8183 references, 39 jurisdiction-wide surveys conducted between 1990 and 2010 were identified. Of those, 22 surveys used sufficiently similar research methods to allow further statistical analysis. Significant differences were found across surveys in the frequency of treatment withdrawal, use of opiates or sedatives and the intentional use of lethal drugs (X² > 1000, p < 0.001 for all). Regression analyses showed increased use of opiates and sedatives over time (p < 0.001), which could reflect more intense symptom management at the end of life, or increase in these drugs to intentionally cause patients’ death.

Conclusion

The use of opiates and sedatives appears to have significantly increased over time between 1990 and 2010. Better distinction between practices with different legal status is required to properly interpret the policy significance of these changes. Research on the effects of public policies should take a comprehensive look at trends in end-of-life practice patterns and their associations with policy changes.

Meta-Review of the Quantity and Quality of Evidence for Knee Arthroplasty Devices

INTRODUCTION

Some cardiovascular devices are licensed based on limited evidence, potentially exposing patients to devices that are not safe or effective. Research is needed to ascertain if the same is true of other types of medical devices. Knee arthroplasty is a widely-used surgical procedure yet implant failures are not uncommon. The purpose of this study was to characterize available evidence on the safety and effectiveness of knee implants.

METHODS

A review of primary studies included in health technology assessments (HTA) on total (TKA) and unicompartmental knee arthroplasty (UKA) was conducted. MEDLINE, EMBASE, CINAHL, Cochrane Library and Biotechnology & BioEngineering Abstracts were searched from 2005 to 2014, plus journal tables of contents and 32 HTA web sites. Patients were aged 18 and older who underwent primary TKA or UKA assessed in cohort or randomized controlled studies. Summary statistics were used to report study characteristics.

RESULTS

A total of 265 eligible primary studies published between 1986 and 2014 involving 59,217 patients were identified in 10 HTAs (2 low, 7 moderate, 1 high risk of bias). Most evaluated TKA (198, 74.5%). The quality of evidence in primary studies was limited. Most studies were industry-funded (23.8%) or offered no declaration of funding or conflict of interest (44.9%); based on uncontrolled single cohorts (58.5%), enrolled fewer than 100 patients (66.4%), and followed patients for 2 years or less (UKA: single cohort 29.8%, comparative cohort 16.7%, randomized trial 25.0%; TKA: single cohort 25.0%, comparative cohort 31.4%, randomized trial 48.6%). Furthermore, most devices were evaluated in only one study (55.3% TKA implants, 61.1% UKA implants).

CONCLUSIONS

Patients, physicians, hospitals and payers rely on poor-quality evidence to support decisions about knee implants. Further research is needed to explore how decisions about the use of devices are currently made, and how the evidence base for device safety and effectiveness can be strengthened.

Children’s Salivary Cortisol, Internalising Behaviour Problems, and Family Environment: Results from the Concordia Longitudinal Risk Project

To explore the possibility that children’s adrenocortical reactions to parent-child conflict influence their vulnerability for internalising behaviour problems, we studied 62 mother-child dyads from the Concordia Longitudinal Risk Project. Standardised measures of maternal, child, and family adjustment were collected. Mother’s and children’s saliva was sampled before and after a conflict-oriented mother-child interaction task and was later assayed for cortisol. The children’s pre-task cortisol scores were negatively associated with their internalising behaviour problems, their mother’s childhood levels of socially withdrawn behaviour and current psychosocial problems, as well as dimensions of family environment representing the open expression of aggression, anger, and conflict. Children’s cortisol levels after the interaction task were lowest for those raised by mothers with high childhood levels of aggressive behaviour problems, and in family environments characterised by rigid rules. Interrelationships between mother and child pre- and post-task cortisol levels were associated with maternal levels of childhood behaviour problems. The integration of measures of children’s adrenocortical activity into developmental studies of children at risk for psychosocial problems may reveal important clues regarding the processes by which adverse early rearing environments affect children’s internalising problem behaviour.

Feasibility and outcome evaluation of a telemedicine application in speech–language pathology

This evaluative study assessed the feasibility and outcome of delivering speech–language services from a distance to children and adolescents who stutter. All six patients who formed the first cohort seen in the telespeech programme were included in the study. The results demonstrated that interactive videoconferencing can provide a feasible and effective care delivery model. Patient attendance was maintained throughout the intervention. All participants showed improved fluency. Stuttering ranged from 13% to 36% before treatment and 2% to 26% after treatment. All participants maintained at least part of their improved fluency during the six-month follow-up, when stuttering ranged from 4% to 32%. The study demonstrates that full assessment and treatment of stuttering in children and adolescents can be accomplished successfully via telemedicine.

How does venture capital operate in medical innovation?

While health policy scholars wish to encourage the creation of technologies that bring more value to healthcare, they may not fully understand the mandate of venture capitalists and how they operate. This paper aims to clarify how venture capital operates and to illustrate its influence over the kinds of technologies that make their way into healthcare systems. The paper draws on the international innovation policy scholarship and the lessons our research team learned throughout a 5-year fieldwork conducted in Quebec (Canada). Current policies support the development of technologies that capital investors identify as valuable, and which may not align with important health needs. The level of congruence between a given health technology-based venture and the mandate of venture capital is highly variable, explaining why some types of innovation may never come into existence. While venture capitalists' mandate and worldview are extraneous to healthcare, they shape health technologies in several, tangible ways. Clinical leaders and health policy scholars could play a more active role in innovation policy. Because certain types of technology are more likely than others to help tackle the intractable problems of healthcare systems, public policies should be equipped to promote those that address the needs of a growing elderly population, support patients who are afflicted by chronic diseases and reduce health disparities.

Comparing end-of-life practices in different policy contexts: a scoping review

Objectives

End-of-life policy reforms are being debated in many countries. Research evidence is used to support different assumptions about the effects of public policies on end-of-life practices. It is however unclear whether reliable international practice comparisons can be conducted between different policy contexts. Our aim was to assess the feasibility of comparing similar end-of-life practices in different policy contexts.

Methods

This is a scoping review of empirical studies on medical end-of-life practices. We developed a descriptive classification of end-of-life practices that distinguishes practices according to their legal status. We focused on the intentional use of lethal drugs by physicians because of international variations in the legal status of this practice. Bibliographic database searches were supplemented by expert consultation and hand searching of reference lists. The sensitivity of the search strategy was tested using a set of 77 articles meeting our inclusion criteria. Two researchers extracted end-of-life practice definitions, study methods and available comparisons across policy contexts. Canadian decision-makers were involved to increase the policy relevance of the review.

Results

In sum, 329 empirical studies on the intentional use of lethal drugs by doctors were identified, including studies from 19 countries. The bibliographic search captured 98.7% of studies initially identified as meeting the inclusion criteria. Studies on the intentional use of lethal drugs were conducted in jurisdictions with permissive (62%) and restrictive policies (43%). The most common study objectives related to the frequency of end-of-life practices, determinants of practices, and doctors’ adherence to regulatory standards. Large variations in definitions and research methods were noted across studies. The use of a descriptive classification was useful to translate end-of-life practice definitions across countries. A few studies compared end-of-life practice in countries with different policies, using consistent research methods. We identified no comprehensive review of end-of-life practices across different policy contexts.

Conclusions

It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice.