Assignment 2 Forum

I think we definitely want to review the literature about the gap of interest, and a good way to interact with that literature is through one or more of the theories that we reviewed.  

 

Let’s say you are interested in something relatively broad, like “comprehensive geriatric assessment” which is what one of our co-conspirators in this class is going to tackle.  Not knowing much about this topic, I googled it and turns out there is a UpToDate page on it which is very intriguing.   Overall I learned that it is multidisciplinary and comprehensive assessment and management of frailty.  This approach can take many forms for use in the community and in facilities and has shown effects on a range of outcomes from depression to falls, poly-pharmacy etc.

 

So now you’ve been asked to come up with a diagnosis of the gap.  Where to start?

 

The first question is whether there is something here (comprehensive geriatric assessment) to implement (and we want to understand that) or whether comprehensive geriatric assessment itself is the thing we want to learn more about.  In other words, is CGA the EBI we want to spread?  Or is it a philosophy or a perspective? The answer to this question is not completely obvious to me. 

 

But let’s say it is, that is to say that there are a set of practices that have known and measurable effect on health and quality of life in the elderly, then the question becomes why these practices are not used – say in the outpatient setting. To answer this question here are your tools:

 

1.   Your contextual knowledge

2.   Theory

 

Using theory… On a socio-ecological level, you are dealing with at least individual provider attitudes, organizational capacity / attitudes, community standards, and policy environment.   You can pursue any of these. 

 

CFIR might get you to think systematically through the problem as well.  What is happening at the policy level?  What about at the organizational level? You could think through things – I think in my opinion the problem is at the level of the facility. 

 

I think you are saying that this practice isn’t offered so perhaps it is more important to look at supply side.  I think that makes the health belief model less useful.  The diffusion of innovations might yield some insights here form the provider perspective: what is the relative advantage? Observable? Trialable?   The COMB offers insights.  I think all three are in play: organizations probably don’t know how to implement this and they probably don’t know where to get trained.  Still I would need to whittle these candidate perspectives into one particular formulation. 

 

You can go though all the theories we discussed and try them on like a dress or a suit at the store, take a look, and see if you think there is a fit. 

 

To me, not knowing more, it seems like the activation energy to start something like this would be deeply disruptive.  This reminds me of the idea of “cost of change” which is a theory in organizational studies based on the idea that there are routines and processes around any set of organizational practices, and that there is a cost both psychologically and in monetary terms, in changing.   So, not knowing more about this, I might hypothesize that the barrier to change is “organizational entropy.” 

 

If that were the case, then there are some interventions targeting this in particular:

 

 

Article Source: Celhay, Pablo, Paul Gertler, Paula Giovagnoli, and Christel Vermeersch. “Long Run Effects of Temporary Incentives on Medical Care Productivity.” National Bureau of Economic Research Working Paper 21361, 2015.