Master’s Thesis in Medicine with Industrial Specialization, Medical Market Access What innovation characteristics are perceived important in the diffusion and adoption process of advanced medical equipment in Danish public hospitals | By Claus S. von Arenstorff 31-05-2018 DIFFUSION AND ADOPTION OF INNOVATIONS IN DANISH PUBLIC HOSPITALS
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Master’s Thesis in Medicine with Industrial Specialization, Medical Market Access
What innovation characteristics are perceived important in the diffusion and adoption process of advanced medical equipment in Danish public hospitals
| By Claus S. von Arenstorff
31-05-2018 DIFFUSION AND ADOPTION OF INNOVATIONS IN DANISH PUBLIC HOSPITALS
Pages: 79 (incl. appendix) Word count: 30.166 (incl. appendix) Submission date: May 31
st 2018
Abstract
Title: Diffusion and adoption of innovations in Danish public hospitals
Background: Diffusion and adoption of innovations in public hospitals is a complex process, where many stakeholders
must be taken into account. With the theoretical framework proposed by Everett Rogers, this thesis aim to elucidate
important innovation characteristics that can explain the diffusion and adoption process of innovations in Danish
public hospitals. Two innovations - The leksell gamma knife, and the da Vinci surgical robot, is used to elucidate
important innovation characteristics from decision managers.
Method: A literature search was conducted to obtain information about the two innovations, and what characteristics
they have. They were evaluated on the relative advantage, compatibility, complexity, trialability and observability.
Interview with four decision managers were conducted, in order to confirm or reject the findings made.
Results: The leksell gamma knife have a significantly slower diffusion and adoption compared to the da Vinci. The
difference may partly be caused by a greater complexity and high cost which doesn’t justify its relative advantage.
Furthermore, the da Vinci has a great appeal to doctors in more than one way, which may play a key role.
Conclusion: In terms of highly advanced surgical equipment it was found; the relative advantage is the most important
characteristic. Especially increased patient care, and appeal to doctors. Both the complexity and observability may
play an important role, due to the political influence asserted into the public Danish hospitals. Compatibility and
trialability was found to be less significant, although it is factors decision managers do consider and take under
consideration prior to taking a decision.
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Table of content:
1. Introduction Page 4
2 Problem Statement Page 5
2.1 Structure of the project Page 6-7
3. The included innovations Page 8
3.1 Leksell Gamma Knife Page 8-9
3.2 Da Vinci Surgery Systems Page 10-11
4. Background Theory Page 12
4.1 Introduction to innovation theory Page 12
4.2 Diffusion of innovations and adaption Page 12-14
4.3 Characteristics of health care innovations Page 14
4.3.1 Relative Advantage Page 14-15
4.3.2 Compatibility Page 16
4.3.3 Complexity Page 16-17
4.3.4 Trialbility Page 17-18
4.3.5 Observability Page 18-19
4.4 The innovation-decision process Page 19
4.4.1 Knowledge Page 20
4.4.2 Persuasion Page 21
4.4.3 Decision Page 21
4.4.4 Implementation Page 21-22
4.4.5 Confirmation Page 22
4.5 The Danish public hospital sector Page 22-23
5. Methods Page 24
5.1 Research design Page 24
5.1.1 Literature search Page 24-25
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5.1.2 Interview Page 25-26
6. Results Page 26
6.1 Adoption of the innovations Page 26-28
6.2 Findings from literature search Page 29
6.3 Findings from interview Page 29-33
6.3.1 Rated perception of innovation dynamics Page 34
7. Discussion Page 35-40
8. Conclusion Page 41
9. References Page 42-48
10. Appendix Page 49
10.1 Appendix 1 – Letter of consent Page 49
10.2 Appendix 2 – Interviewguide Page 50-51
10.3 Appendix 3 – Transcription of Interview 1 Page 52-59
10.4 Appendix 4 – Transcription of Interview 2 Page 60-68
10.5 Appendix 5 – Transcription of Interview 3 Page 69-75
10.6 Appendix 6 – Transcription of Interview 4 Page 76-79
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1. Introduction
This thesis focuses on the association between innovation characteristics and innovation adoption in the
Danish hospital sector. When introducing an innovation for a public organization like a hospital, three major
influencers can affect the innovation adoption – organizational characteristics, decision maker
characteristics and innovation characteristics. This interrelation is illustrated in figure 1.
Figure 1 - The interrelation between innovation characteristics, decision maker characteristics, organizational characteristics and innovation adoption.
Organizational innovation researchers argue that innovation adoption is a response to changes in
organizational characteristics. This could be an increase in patients, which calls for innovation to treat more
patients, or treat them faster with the same quality of care. Or innovative solutions that can complement
an inexpedient composition of employees, or reduce the need of coveted qualifications. If there is a need
for the innovation from an organizational point of view, the probability of successful innovation adoption is
greatly increased. However, due to other influencers it is not a matter of course. Decision makers and their
characteristics possess great power when it comes to reject or acquire an innovation. A study shows that
personal characteristics among decision makers play a crucial role when it comes to innovation adoption.
(2) Examples of personal characteristics are education, gender and attitude towards innovations. The
characteristics of the organization and the decision makers seem mostly out of hands of the business. What
are in the hands of the business though are the innovation characteristics. The innovation characteristics
often described are relative advantage, compatibility, complexity, trialability and observability. These were
first introduced by Everett Rogers, during his work with the diffusion of innovations theory. (1) Over time
there have been several attempts to develop general scales for measuring the influence of innovation
characteristics on the adoption process, Rogers though argue that no such unifying framework exists.
However, within a highly specific context, already existing innovations can provide information about
preferable characteristics for future innovations (2). In this thesis two already implemented innovations in
the Danish health care sector will be studied in order to elucidate preferable characteristics for future
innovations. The two innovations are Da Vinci Surgical Robot and Gamma Knife.
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2. Problem Statement
The aim of this project is to elucidate which innovation characteristics have the highest influence on
adoption of innovations in the Danish health care system. To answer this, the following problem statement
has been deduced:
It is known from the literature, that no unifying framework of innovation characteristics exists. However,
within a specific context, characteristics of successfully implemented innovations can be used for indicative
purposes. The specific context is not defined anywhere in the literature, so it may be up to an individual
interpretation of when it is specific enough. I interpret advanced surgical equipment as a specific context,
which leads me to the selection of the included innovations in this study. The included innovations are the
Leksell Gamma Knife and the Da Vinci Surgical Robot, which both are technical advanced innovations used
for surgical purposes.
This framework can be used by anyone who wants an innovation adopted by the Danish hospitals, but may
be of much greater interest to those who invent, manufacture and sell equipment similar to those included
in the study. Great resemblance between a future innovation and included innovations, the more usable
will the findings of this study be, hence the specific context of the innovation.
With a foundation in two existing innovations, how do the perception of
innovation characteristics influence the diffusion and adoption process, and
what characteristics are emphasized in the context of highly advanced
surgical equipment in Danish public hospitals.
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2.1 Structure of the project
The purpose of this chapter is to give the reader a general understanding of the report, and its structure.
Figure 2 has been made to give a visual illustration of the overall report.
In the beginning an introduction gives the reader a brief understanding of the theories used, the aim of this
report, and more specifically what it will concern. The project aims to elucidate important innovation
characteristics that can predict diffusion and adoption of innovations in the Danish health care system,
which the problem statement will describe. To do so, two already implemented innovations will be
examined. The two innovations are the gamma knife, and the Da Vinci Robot. During the introduction, a
general description of both innovations is made, which serves the reader with a general understanding of
the innovations.
During the theoretical part of the report, the reader will be introduced to fundamental innovation theory.
Everett Rogers will be the primary source of information for this chapter, and his theory about diffusion of
innovations. As a part of the theory section, the innovation characteristics: Relative advantage,
compatibility, complexity, trialability and observability will be described in reference to the two
innovations. To describe them in that context, a literature search for both innovations is performed.
To complement the findings in the literature, several semi-structured interviews are conducted with
members of different buying units at different Danish hospitals. On model X, the blue part describes the
theoretical research (which is done for both innovations), and the green part describes the experimental
research (which is also done for both innovations).
At the end of the report, the findings from both the theoretical research and the experimental research, is
brought together to elucidate which innovation characteristics are emphasized in the context of highly
advanced surgical equipment, and what is the perception of innovation characteristics from a buying unit
perspective.
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Figur 2 – A visual illustration of the report. Two innovations (Gamma Knife and Da Vinci Robot) is used in order to find innovation characteristics with impact on the diffusion and adoption process. The methodology in this study is literature search, and a semi-structured interview will be conducted in order to support the findings made in the literature.
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3. Included innovations
3.1 Gamma knife
The gamma knife (also known as Leksell Gamma Knife (LGK)) is a creation of Lars Leksell, a Swedish
professor and neurosurgeon, and Börje Larsson, a Swedish professor of physical biology. The LGK uses a
technique called stereotactic radiosurgery, where highly-focused beams are aimed at a specific defined
area inside the brain to cause a lesion. The very first LGK was invented in 1968, as a result of decades of
research into the art of performing non-invasive intracranial surgery. However, that model is nothing like
the models available today. Originally the LGK was invented to treat functional neurological disorders,
where it can benefit the patient to have specific parts of the brain damaged. As medical imaging techniques
improved dramatically during the 80s, it became possible to target intracranial arteriovenous
malformations and tumors with the LGK, which to this day remain a purpose of the LGK. (3) That sparked
the adoption of the innovation, which begun in 1984 with the installation of gamma knife systems in UK
and Argentina. In 1987 the first patient was treated in the U.S, and in 1995 the first gamma knife was
installed in Denmark. (4, 5) In 2012 LGK number 500 was manufactured, resulting in an installation base of
300 systems worldwide (6). The closest competitor to the LGK is the LINAC (linear accelerator), which like
the LGK is a radiation therapy.
The LGK functions by emitting up to 201 precisely focused beams of cobalt-60 gamma radiation. The beams
are emitted from different directions, into an exact spot inside the patients’ brain. A visual illustration can
be found on Image 1. The beams are single handedly not powerful enough to cause any significant damage,
as they move through the tissue. But when they’re all collectively aimed for the exact same spot, they are
able to cause great damage to that spot, while surrounding tissue remain largely unharmed. (7) The
procedure is typically performed under local anesthesia. However, patients unable to cooperate such as
kids and mentally ill may be put under full anesthesia. A special frame is then placed around the head of
the patient, and attached with screws to keep the head of the patient in place. The main function of the
special frame is the in-built technology. It provides the LGK with a three-dimensional coordinate system,
which divides the brain of the patient into small segments. Imaging techniques are then performed, e.g. MR
or CT, to get the exact location and size of the desired target. Imaging results are then sent to the software
of the LGK. Beams can now be emitted to a very precise location inside the three-dimensional coordinate
system, because of the special head frame. During the treatment, the software gives input to an advanced
robotic technology that moves the patient with submillimeter increments, in order to effectively treat
targets with different shapes and sizes. (8)
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Image 1 (29), a visual illustration of how the gamma knife functions. A patient is placed on a board, which goes into a machine. Inside the machine 201 gamma rays will be precise aimed at a spot inside the brain, in order to remove it.
If the target is below four centimeters in size, it is treatable in one session. This goes for the majority of
treatments performed. A treatment can take anywhere from minutes to several hours depending on the
shape and size of the target, but usually takes 30 to 60 minutes. The most common conditions treated with
LGK are arteriovenous malformations and brain tumors – both benign and malignant. Indications for LGK
usage are small tumors, deeply situated tumors that can’t be reached by standard surgery, and patients not
suited for traditional open-brain surgery, e.g. elder or weak patients who can’t undergo full anaesthesia.
Gamma knife is currently the preferred method of choice, when it comes to removal of small intracranial
tumors. (9)
During treatment a multidisciplinary medical team consisting of a radiation oncologist, a medical physicist,
a neurosurgeon, a nursing crew, a radiation therapist and possibly an anesthesiologist takes care of the
patient. All medical professionals attending, except the anesthesiologist, have typically received special
training in the LGK. It is a requirement, that at least one member of the medical team is an “authorized
user”, and have control of the treatment console during the entire length of the procedure. To become an
“authorized user” one must attend a special course giving theoretical and practical knowledge about the
LGK. The course will take four weeks to complete, and continuous training will be needed to keep up with
new upgrades. (10)
Because the LGK have been reinvented since the launch of its first model, multiple models are today
available. Each model has different properties and usability, but the emphasis of this project will be put on
the Leksell Gamma Knife Perfexion. The perfexion model, is the model with greatest resemblance to the
first models, and is the flagship of gamma knifes. The acquisition cost of the perfexion model is $3.2 million
USD, and an additional cost of $675,000 USD for installation and software. Additional cost of yearly
maintenance is typically 0.5% of acquisition cost, which is approximately $20.000 per year. (11, 12)
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3.2 Da Vinci Surgical Systems
The Da Vinci Surgical System (from now on Da Vinci) is a creation of the American company Intuitive
Surgical. The Da Vinci innovation is a result of two other innovations merging. One of the innovations is the
master-slave robotics technology, where a robotic arm controlled by a human is used to move objects. The
master-slave technology was developed during the 50s and 60s. The other innovation is the medical
procedure laparoscopy. Laparoscopy is a minimal invasive surgical procedure, where a surgeon makes a
small hole in the skin, and inserts the surgical instruments necessary to perform the procedure including a
small camera for visual guidance (a laparoscope). This surgical procedure was greatly improved, and met
general acknowledgement, during the late 80s. The merging of the master-slave robotics technology and
modern laparoscopy gave rise to the Da Vinci – a computer-assisted surgical robot responding to inputs by
surgeons to perform precise, delicate and complex surgical procedures with minimal invasions. (13)
In 1999 Da Vinci was introduced to the market, and received quickly widespread attention and
acknowledgement, after FDA approved it in 2000 – the first robot to be FDA approved. Five years should
go, before the technology had reached Denmark. The first medical procedure performed in Denmark on a
Da Vinci was found to be a prostate cancer procedure in 2005 (14), and is now considered a fixture in most
Danish surgical departments. As of December 2017, 4271 Da Vinci robots were installed worldwide
performing a total of 850.000 procedures in 2017. (15)
The Da Vinci consists of two vital components – the tower, and the console. The tower consists of four
robotic arms, holding up to four surgical instruments needed for the procedure. One of these instruments
is a small 3D camera, used for visual guidance inside the patient. The tower is placed in direct relation to
the patient, in order to be able to perform the procedure. The tower is connected to the console with a
cable, in order to make latency literally none existing. At the console a surgeon, responsible for performing
the procedure, is sitting in a comfortable chair. At his disposal is a high resolution 3D image for visuals, as
well as handles and foot pedals to control the arms. With available pedals, the surgeon can adjust the
power of the robot arms, to give a very high precision when needed. The medical staff attending a Da Vinci
procedure is equivalent to the medical staff attending a conventional laparoscopy procedure. Only
difference is the capabilities and preferences of the surgeon. One must be trained to do conventional
laparoscopy, or trained to perform Da Vinci procedures. An overview of the operating room during a Da
Vinci procedure is illustrated in image 2. (16) The procedures eligible to be performed on a Da Vinci is
equivalent to procedures performed with conventional laparoscopy. That includes cardiac surgery,
colorectal surgery, gynecologic surgery, head and neck surgery, thoracic surgery, urologic surgery and many
kinds of general surgery such as cholecystectomy or appendectomy. (17)
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Image 2 (31), a visual illustration of how the operation room could be arranged.
The main advantages of the Da Vinci system opposed to conventional laparoscopy are: Better ergonomics,
better visibility and better handling of instruments. During some procedures, the better handling of
instruments implies decreased blood loss, slightly decreased mortality rate (0.097%) and fewer days
admitted compared to conventional laparoscopy surgery. The disadvantages of the Da Vinci are longer
operative time, a complex installation process and a high acquisition cost. Especially the high acquisition
cost is considered a prohibitive factor for some hospitals, when it comes to acquiring the Da Vinci. But
when the cost of the procedure and admission is considered, the Da Vinci is found to be a cost-effective
solution by some studies, compared to both conventional laparoscopy and open surgery (18, 21). The
admission time for Da Vinci surgery is averaging 4.9 days, for conventional laparoscopy 6.1 days. The
median cost of performing a procedure on Da Vinci is found to be $30,540 while the cost of conventional
laparoscopy is found to be $34,537. (18, 19) However, other studies find the exact opposite – which is the
Da Vinci is not cost-effective to acquire and use (22, 23). The results of cost-effective analysis in this field
are susceptible to how many patients are included, and which procedures are used in the calculations, as
some procedures are more cost-effective to perform on the Da Vinci than others.
The acquisition cost of acquiring a Da Vinci ranges from $0.5M - $2.5M. Instruments and accessories range
from $700 – $3,500. Typically instruments for the Da Vinci can only be used a certain amount of times,
ranging from one to a hundred procedures, which shall be calculated as an ongoing cost. The service
contract ranges from $80,000 to $170,000 per year. The average Da Vinci typically cost between $1.5M and
$2.2M. (15, 20)
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4. Background Theory
4.1 Introduction to innovation theory
There are different types of innovation. An innovation may typically be thought of as either an incremental,
substantial or a radical innovation (24). That is the three levels of innovation (25). Incremental innovations
are typically small, but important improvements and features added to a product to enhance its value and
give a competitive advantage compared to similar products in the market (25). Substantial or semi-radical
innovation is a greater change to the product than what is seen in incremental innovations. Typically
substantial innovation involves a degree of change in business model and technology (25). Radical
innovation is the highest level of innovation, and involves a great change or an invention of a completely
new demand. Radical innovations possess the capability to disrupt a market, eliminate existing industries or
force them to transform and adapt in order to survive. (25)
Researchers have previously presented different theories related to innovation research. The Austrian born
economist Joseph Schumpeter, who is believed to be one of the first in the field of innovation research,
argued that market power and economic changes, was based on innovation and entrepreneurial activities.
Instead of dumping prices and cutting margins, companies should focus on rethinking the business model
and rethinking the product portfolio. Any new profitable improvements made, is according to Joseph
Schumpeter innovation. (26) While that definition is considered very wide, other researchers such as
Amabile et al. defines the term innovation more narrowly – “innovation is the successful implementation of
creative ideas within an organization” (27). Everett Rogers who will lay the theoretical foundation of this
paper defines innovation as: “Innovation are a broad category, relative to the current knowledge of the
analyzed unit. Any idea, practice or object that is perceived as new by an individual or other unit of adoption
could be considered an innovation available for study.” (1)
With those three definitions in mind, all of the included innovations for this thesis pass on the definition.
However, whether or not they are implemented successfully within the health care organization can be
brought up for discussion.
4.2 Diffusion of innovations and adoption
Diffusion of innovations is a theory presented by Everett Rogers. The theory aims to explain how, why and
at what rate new innovations spread throughout a social system (1). The social system could for an instance
be health care organizations. Rogers define diffusion as “the process by which an innovation is
communicated over time among the participants in a social system.” If an innovation is indispensable, and
possesses some great characteristics, the participants of a social system will be more likely to communicate
its findings to friends and colleagues, and that is how the knowledge of an innovation spread to adopters
over time. Once people are informed about the innovation, they have to decide whether or not to adopt it.
Rogers call this rate of adoption, and define it as “the relative speed with which an innovation is adopted by
members of a social system.” Adopters can be seen as both people or organizations in the social systems,
who decide to acquire the innovation. Rogers have made five distinguished categories of adopters, based
on their willingness to adopt an innovation:
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Figur 3 (1). The diffusion of innovations based on adopter characteristics according to Everett Rogers.
Innovators are the first group of people, who are willing to acquire a brand new innovation. The innovators
typically have liquidity to make risky investments, and a great willingness to take risks. Of the five
categories, the innovators are typically the youngest in age, and have a high social class. The majority of
innovators are males, who have a close social connection to the innovative part of their industry. The
connections typically arise from meetings at fair trades, through reading scientific research papers, and just
in general being aware of new tendencies in the industry. According to Rogers the Innovators only consist
of approximately 2.5% of a target population, but they are of great importance to get proof of concept,
which will help acquire early adopters. (1)
Early adopters are the second fastest group of people, who are willing to acquire a new innovation. Like
the Innovators, early adopters have financial liquidity to make risky investments, although their willingness
to take risks is lower than Innovators. It is not uncommon for early adopters to observe the group of
innovators for risk assessment. Early adopters are typically young in age, have a high social status, an
advanced education, and are socially forward compared to late adopters. Early adopters are of great
importance for the innovation diffusion process. Due to a high degree of opinion leadership, early adopters
have great capabilities of spreading the knowledge of an innovation throughout a social system. (1)
Early majority is a large group of people, where both the diffusion and adoption process takes notably
longer time, compared to the previous two groups. The diffusion process is slowed down due to lack of
opinion leadership, which results in minimal communication related to the innovation carried out
throughout the social system. Adoption of an innovation is for the early majority contingent on successful
use by either the innovators or the early adopters, and preferably someone they know from their network.
People in this group typically have above average social status, are less affluent and possess an educational
level below innovators and/or early adopters. (1)
Late majority is a large group of people, who will adopt an innovation on ly after seeing a majority of the
population acquiring it. Knowledge about new innovations typically hit the late majority group long time
after launch. Combined with a general skepticism towards new innovations, the late majority group
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contributes to a slow diffusion and adoption process. People in this segment are generally a bit older than
the previous groups, less educated and are less affluent. People from the late majority typically mingle
with people from early and late majority, showing little opinion leadership. (1)
Laggards are the last group of people to adopt an innovation. People in this group typically have an
aversion to changes, and are afraid of implementing technology they don’t fully understand and
comprehend. Laggards typically prefer to do things, as they always have been done. Furthermore the
laggards are likely to have the lowest social status, socializing with very few people – primarily family. In
general this group of people have very little to none opinion leadership. Laggards have the oldest average
age, and possess the lowest level of education among all adopters. (1)
In order to have a successful diffusion of an innovation, it is important to target the right kind of people
from the beginning. Different characteristics the innovations possess can benefit the diffusion process, and
the rate of adoption. These characteristics were first time introduced by Rogers. These characteristics will
be discussed in the following chapter.
4.3 Characteristics of health care innovations
The purpose of looking into the innovation characteristics is to categorize potential adopters
perceptions of the innovation, for an instance; how does it look, how does it feel, is it easy to use and
how beneficial is it to acquire. Such perceptions will naturally form the intentions of potential
adopters, and will ultimately be what they rely on when making a final decision of whether or not to
acquire an innovation. Rogers have derived five characteristics based on his research, which lay the
foundation of this theoretical framework. The five characteristics are: Relative advantage,
compatibility, complexity, trialbility and observability. (1)
4.3.1 Relative advantage
The relative advantage of an innovation describes the more potential value adopters can obtain from
acquiring the innovation, compared to alternative solutions. Rogers define relative advantage as: “…
the degree to which an innovation is perceived as being better than the idea it supersedes.” (1) A
relative advantage can for an instance be of economic character (i.e. low acquisition cost, or low
running cost), social character (i.e. prestige in community, or greater appeal to job seekers) or
performance character (i.e. treat patients better, or treat patients faster with same level of quality)
just to name some. Anything that can be perceived as an advantage compared to the existing situation,
can be considered a relative advantage. (28) Needless to say, one innovation may have many relative
advantages, but only those perceived as relative advantages by the decision makers affect the
intentions of adoption in a positive direction.
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Relative advantages of the Da Vinci
According to the company behind the Da Vinci, Intuitive Medical, there are several relative advantages
to their product. The relative advantages stated by Intuitive are typically compared to either
conventional laparoscopy, open surgery or both. The relative advantages are:
Decreased variability in surgeon performance.
Better opportunities to train procedures, and become better surgeons.
Better comfort for the surgeon during a surgery.
Better intracavitary vision during surgery.
Better patient care (reduced length of admission, reduced complications, fewer readmissions
and lower infection rates). (15)
All relative advantages stated above are of a performance character. It is known from the literature
that the Da Vinci is superior to open surgery both in terms of patient care and economy. However,
compared to conventional laparoscopy, there are mixed results. Some results point in favor of using
the Da Vinci, and some in favor of using conventional laparoscopy. The Da Vinci has better
performance when it comes to certain procedures, while conventional laparoscopy remains the
dominating method when it comes to other procedures (30). Some procedures doesn’t have a
difference in performance, but is likely a matter of preference from the surgeon to determine
technique used. We also know from the literature, that the Da Vinci can both be cost-effective and
not. It depends on the circumstances, and the setting in which the Da Vinci is implemented. If there
are enough procedures to be performed, and the procedures are highly suitable for the Da Vinci, it will
most likely be cost effective in that scenario. (30, 32)
Relative advantages of LGK
As mentioned in the introductory section about LGK, the alternative to LGK is in most cases the LINAC.
LINAC possesses the ability to carry out radiosurgical treatments similar to the LGK. If the hospital has
a need for radiosurgical equipment, LINAC would likely be the second option for intracranial
procedures. Therefore the relative advantage of the LGK is compared to the LINAC. The primary
relative advantages of the LGK are:
High accuracy in delivering radiation, which spares surrounding tissue. The LINAC gives 2-6x
higher dose to normal brain tissue, than the LGK.
Higher precision in targeting.
Session duration time is shorter. (33)
The relative advantages of the LGK reflect the performance of the innovation, which can lead to better
patient care. However, a retrospective comparative study with a total of six studies found no
difference in the clinical outcomes between the LGK and the LINAC (34). It is speculated though, that
the more damage the LINAC inflict on surrounding tissue, can show up in a study with a longer time
horizon. Shorter session duration time can also be of an economic character. Choosing the LGK
opposed to the LINAC, hospitals can treat more patients with same quality of care. A cost comparing
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study between the LGK and the LINAC concludes the LGK is the most favorable alternative, if the
hospital has a larger number of patients (>200 p.a.) (35).
4.3.2 Compatibility
Rogers define compatibility as: “… the degree to which an innovation is perceived as consistent with
the existing values, past experiences, and needs of potential adopters.” (1) Compatibility describes the
ability of an innovation to fit directly into a setting, without further actions of the adopter. This can for
an instance be the ability to coexist with other already existing equipment. If the innovation depends
on other technology, or other technology depends on the innovation, it is important for the diffusion
and adoption process, that these technologies is compatible and can coexist without further cost for
the adopters. (28)
Compatibility of Da Vinci
A lot of modern compatibility issues arise when two independent systems need to communicate with
each other. That is not the case with the Da Vinci. The Da Vinci is a complete system, consisting of a
surgeon console and a tower. No interactions with other systems are made, or needed, which
essentially makes the Da Vinci a “plug-n-play” solution for surgeons. But, if surgeons don’t like the
properties defined in the software, they cannot alter it. The software used is proprietary, and can only
be edited by Intuitive Surgical. However, it is very rare any surgeon may want to alter these settings.
The compatibility of the Da Vinci is generally not considered a prohibitive factor for adoption. (36)
Compatibility of LGK
When using a LGK, imaging services must be performed prior to the actual procedure. In the Gamma
Knife Perfexion, imaging services can be performed at a MRI or CT scanner. Imaging results will be sent
to the Gamma Knife planning computer system, where doctors can precisely aim the beams based on
the location of the target. The MRI or CT scanner performing the imaging services does not need to be
of a specific brand or modality. When an imaging service is performed, the output will be images in a
specific file type, which the gamma knife planning computer system will be able to read. Newer
models of the gamma knife, such as the Gamma Knife Icon have in-built imaging services. (8, 37)
4.3.3 Complexity
Rogers define complexity as: “… the degree to which an innovation is perceived as relatively difficult to
understand and use.” (1) The complexity of an innovation is negatively related to the rate of adoption,
while simplicity is positively related to the rate of adoption. An innovation considered easy to
understand, and easy to use, is more likely to have a positive diffusion and adoption process (28). But
as highly complex innovations are common in the health care sector, it can be argued that it doesn’t
affect the diffusion and adoption process as much as it would in other industries. When new
equipment is introduced to the health care market, both doctors and nurses are aware of the learning
process it includes. Furthermore, both doctors and nurses are used to read, learn and absorb new
information, which makes them great candidates for complex innovations. It is very likely though, it
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may slow the diffusion and adoption; since time must be spend from adopters, to learn the
innovations. (38)
Complexity of Da Vinci
The Da Vinci is a very complex piece of engineering. It took many years to develop, consists of more than
2700 parts, and contains more than 1.1 million lines of software code. But even though it is a very complex
machine, it is relatively simple to understand and use. The Da Vinci innovation aim to replace conventional
laparoscopy procedures, which is a procedure all most surgeons are familiar with. With that in mind,
surgeons can easily understand the usage and functionality of the Da Vinci. A Dutch study shows the main
source of training comes from the manufacturer (intuitive surgical), and/or local courses with an
experienced colleague. A majority of the population in the study (p=56), expressed to have received only 5
hours of basic training or even less. Most of the training is carried out after a learning-by-doing principle, on
real life human beings, with an experienced surgeon as a supervisor. In the study though, all surgeons with
no exception had experience with laparoscopy procedures. (39) To me, that indicates the Da Vinci is an
innovation, that is both easy to understand and easy to use.
Complexity of LGK
The LGK is a very complex innovation, both to understand and to use. The LGK is based upon an
advanced biophysics principle, where radioactive gamma beams are aimed at a target. In order to
understand how the beams are emitted, one might need a degree in physics to completely
understand. How the emitted beam affects the cells in the brain, one might need a degree in medicine
to understand. In order to understand the LGK, and decrease uncertainty for this innovation, the
decision-making group should be of a multidisciplinary origin. Furthermore, it is an advanced machine
to use, and takes a four weeks course to get authorization to use it. But the entire team working on the
OR, needs to be educated on the LGK, and receive special training on the matter. The complexity of the
LGK is also reflected in the installation process. From beginning of installation, to beginning of
commissioning, it typically takes about 4-5 weeks. To install the equipment, specialized technicians
must be brought in. (40)
4.3.4 Trialability
Trialability is the ability to try out an innovation in a smaller scale, to test it out before making a total
commitment to the innovation. If the innovation can be tested with minimal investment and no risk,
more people are intrigued to test it out. If an innovation has a high trialability, it greatly influences the
diffusion and adoption rate in a positive direction. Especially early adopters perceive trialability as
important, since it is their opportunity to test the innovation out in practice. Late adopters and
laggards tend to move from trial to full-scale much quicker, because they can see how the early
majority have implemented the innovation. (1)
Trialability of Da Vinci
There are different opportunities available for the potential adopter, to test and try the innovation
before adopting. Intuitive surgical is constantly evolving their training applications, which include a full-
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scale demo edition, where a surgeon can sit at the console and navigate the handles and pedals, like
he would in real life surgery. Instead of a real patient though, the doctor can only see a software made
illustration of how it would look. In this way, the doctor can get a feeling of the mechanics. However,
to get an idea of how the innovation will function in practice, the minimum of one complete system
must be acquired.
Trialability of LGK
The LGK have a very low trialability. In order to test this innovation on a department, the entire system
must be acquired. But it is not enough to acquire a LGK, the department must also have imaging
technology compatible with the LGK available, as it needs imaging services in order to emit beams with
high precision. The smallest quantity of trialability the LGK can match, is one complete system with a
compatible imaging device.
4.3.5 Observability
Rogers define observability as: “… the degree to which the results of an innovation are visibile to
others.” (1) If another possible adopter easily can understand the relative advantage the new
innovation brings, by just observing, it will increase both diffusion and adoption rate. In order to
contribute to a positive rate of adoption, the observed results must be positive and understandable.
Observability may be a particularly important characteristic in the health care sector. It is known from
the literature that hospitals tend to look at other hospitals, for suggestions to improve hospital
performance and patient care (41, 42).
Observability of Da Vinci
The relative advantages of Da Vinci propose reduced length of admission, and fewer readmissions. In
Denmark it has become a well-known problem, that some hospitals are overcrowded from time to
time. The Danish media like to make a fuss out of it, and find a scapegoat (43, 44). If the Da Vinci truly
do reduce length of admission, and cause fewer readmissions, it will imply fewer patients in the
hospitals where the Da Vinci is used. Some may see the correlation, and pick up the Da Vinci as a tool
to reduce overcrowding in hospitals. It will depend though, on how efficient the Da Vinci is in that
matter. According to the studies found, a conclusive statement can’t be made on the matter (18), and
more research is needed on the topic.
Another observable advantage the Da Vinci possesses is the better comfort for the surgeon.
Procedures performed in an operation room may take very long time, and may force the surgeon to
stand in bad positions over a longer time. A study determined to examine the correlation between
surgeons having bad posture during an operation and experienced pain. The study found 80% of the
surgeons in the study to have pain on a regular basis. 46% of those having pain, stated the posture was
the reason. Almost 7% of the population said they had been on sick-leave, as a direct result of pain
caused by bad posture during surgery. With the Da Vinci these numbers may possibly be reduced, and
more surgeons will be available in the workforce. (43)
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Last but not least, some sources (81, 82) points towards Da Vinci being an expensive marketing
gimmick. Some people perceive the Da Vinci as a marker for hospital willingness to develop on existing
procedures to become better. A perception of the newest technology will beat old technology or old
procedures feed this attitude. This leads to two distinct paths: Patients with this attitude, are more
likely to choose hospitals with Da Vinci opposed to hospitals without Da Vinci. Executives and surgeons
are likely to adopt the Da Vinci to maintain their professionalism and pride. Medicine, and especially
surgery, is a very proud and respectable craft. Nobody in this industry likes to be perceived as “being
behind times” or a laggard.
Observability of LGK
The observability of the LGK can appear in different ways, based on the relative advantage it offers. In
Denmark most hospitals are under governmental control, and patients are sometimes referred to another
hospital in another region, if that hospital possesses the ability to perform highly specialized procedures.
The LGK can perform highly specialized procedures. In the introductory part of the LGK, we established the
perception of the LGK is to be a golden standard treatment for intracranial arteriovenous malformations
and cerebral metastasis. Adjacent regions may start referring their patients with those conditions, if they
do not have an LGK themselves, due to the golden standard perception of the LGK.
4.4 The innovation-decision process
The decision to adopt an innovation doesn’t happen instantaneously. Especially in the hospital sector,
where individuals in the decision-unit is responsible for purchasing technologically advanced, and expensive
equipment on behalf of others. Time and contemplation is a must to evaluate the impact an adoption or
rejection of the innovation may or can have. Rogers have described that as the innovation-decision process,
which is a five-step model representing the process a decision-unit goes through. The five stages are
(1)knowledge, (2)persuasion, (3)decision, (4)implementation and (5)confirmation. This model is important,
because it can provide information about the process potential adopters go through: How much time does
it take to adopt/reject an innovation, at what stage in the innovation-decision process do potential
adopters adopt/reject, and what kind of information-seeking does potential adopters perform in order to
decrease uncertainty about the innovation. The model is depicted visually in Figure 4. (1)
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Figure 4 (46). A visualization of the innovation-decision process.
4.4.1 Knowledge
The knowledge stage begins when the decision-unit first time gains knowledge about the innovation. The
decision-unit may have the innovation presented to them by a sales representative, maybe they read about
it in a magazine, or it is introduced to them by friends or colleagues or at an exposition. The amount of
information given to the decision-unit at this stage is often very limited and the amount of knowledge can
be categorized into three groups: Awareness-knowledge, how-to-knowledge and principles-knowledge.
Awareness-knowledge is typically a superficial knowledge about the innovation, giving enough information
to answer what it is. How-to-knowledge is a more technological description of the innovation, giving the
potential adopter an understanding of how it is functioning. Principles-knowledge serves the potential
adopter with the underlying foundation of knowledge leading to why the innovation works.
The importance of which type of knowledge served to what kind of adopter is not without significance, and
can lead to rejection of an innovation based on misunderstandings or lack of knowledge. The superficial
awareness-knowledge typically requires potential adopters to search for deeper understanding themselves.
This can be done through literature or through a social network. Anyhow, it requires adopters to
individually take action. To take action, adopters must generally speaking have some level of higher
education and a pro-innovation attitude. How-to-knowledge naturally requires adopters to have some sort
of technical understanding, in order to fully comprehend the innovation and its possible capabilities.
Principles-knowledge requires the adopter to have an understanding of the surroundings, in which the
innovation is put to use. Typically the most suitable recipient to principles-knowledge, is a person with a
combined theoretical and practical knowledge, who can understand the innovation and imagine how it will
be put to use. The risk of delivering principles-knowledge to inappropriate candidates can lead to misuse
and misunderstanding of the innovation. (1)
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4.4.2 Persuasion
When an individual have gained knowledge about an innovation, the next stage is the persuasion stage. In
the persuasion stage, the potential adopters seek out information on the subject, in order to form an
attitude towards the innovation. The term persuasion in this case does not imply an action performed by an
agent in order to convince someone about something. Persuasion in this context refers to the
interpretation of the information found, which leads to either a favorable or an unfavorable attitude
towards the innovation. Especially information about the innovation characteristics play an important role
in forming the attitude, not to mention the source of this information, how it is delivered and how it is
interpreted.
The attitude is often assumed to pave the way for the decision; to reject or adopt an innovation. However,
this is not always the case. Innovations with a favorable attitude can still be rejected. Similarly can
innovations with an unfavorable attitude be adopted. External pressure on a decision-unit, can lead to
adoption of innovations with an unfavorable attitude. An example of such is the pressure from e.g. the
government, society or management to treat more people faster and more efficiently. Such pressure can
lead to adoption of an innovation with an unfavorable attitude, but a hope that it might function above
expectations, and relieve some of the external pressure.
All innovations possess some degree of uncertainty. How does it perform in a specific setting, what are the
long term consequences of adopting and so on. In order to decrease the uncertainty, a potential adopter
might search for innovation-evaluation information during the end of the persuasion phase, or in the
beginning of the decision phase. Innovation-evaluation information serves the potential adopter with a
better gut feeling when it comes to taking a decision. (1)
4.4.3 Decision
According to Rogers, the decision phase is initiated when the decision-unit starts engaging in activities
where a decision is assumed to be made. The decision can either be to adopt the innovation, or reject the
innovation. Adoption of an innovation is a decision to acquire, and make full use of the innovation, within
the boundaries of what is possible in the organization. Rejection is a decision to not adopt the innovation.
As mentioned in the persuasion chapter, innovation uncertainty plays a large role in the innovation-
decision process. To further confirm the innovation-evaluation findings, most individuals will proceed with
implementing the innovation on a partial basis, or in a small-scale trial presupposed a continued interest.
Partial implementation, or small-scale trials are according to Rogers still a part of the decision process, as a
decision to make full use of the innovation haven’t been made yet, and discontinuance as described in
figure 4 is still a possibility. (1)
4.4.4 Implementation
The implementation phase begins, when the innovation is put into use. Right up until this moment, the
entire innovation-decision process has been a mental exercise, where potential adopters imagine and
conceptualize the implementation of the innovation, and complications that may arise. But at this stage of
the process, the innovation will be put into practice, and unforeseen complications may arise. This can lead
to more questions, more information seeking and possibly a demand for technical assistance. How the
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company reacts to these demands from the adopter can be of great importance, and can possibly lead to
discontinuance if the adopter feels dissatisfied.
During the implementation a re-invention can take place. Re-invention is a utilization of the innovation in
different ways than originally planned. The re-invention is carried out by adopters, and can be the result of
a deliberate action or coincidences. The deliberate re-invention is typically a response from an individual
with a profound knowledge in the field, who sees opportunities to perform a task easier or better with the
aid of the innovation. The coincidental re-invention can take place, when the innovation is misused or
misunderstood. This can especially take place in hospitals, because the people who go through the
innovation-decision process aren’t the same people who are bound to use the innovation on a regular
basis. Innovations that are very complex and process-oriented get re-invented in a higher degree than
innovations that are not.
The implementation phase doesn’t end at a specific time, or after a certain amount of time. It ends when
the innovation becomes a regular part of the adopters’ ongoing operations. For some individuals,
implementation is the final stage in the innovation-decision process. For others, there is yet another phase
called confirmation. (1)
4.4.5 Confirmation
Confirmation is a phase some adopters go through, but not all. The purpose of this phase is to reinforce the
decision made by seeking more information, hence the name confirmation. If new information comes up, it
can either be in harmony or disharmony with the previous decision made (to adopt or reject). If it is in
disharmony, it may change both knowledge and attitude of the adopter which can result in discontinuance
or late adoption. (1)
4.5 The Danish public hospital sector
The Danish health care model is closely similar to the health care model used in England, with a foundation
in the Beveridge model. All permanent residents in Denmark can freely use any service offered by the
Danish hospitals. The services are like in England paid from general taxation. The public hospital sector in
Denmark is approximately five times bigger than the privatized hospital sector, measured on patients
treated per year (47, 48). All public hospitals in Denmark are administered by their respective regions.
Denmark is divided into five regions, which can be seen on image 3. Each region is, among others,
responsible for running the hospitals in their area, and is led by a democratically elected council called the
region council. The region council is responsible for hiring hospital executives, make a budget and enforce
political decisions (49). In each region there is only one purchase department, acting like a joint purchase
department for all hospitals in the area. The majority of all hospital purchases are made through the joint
purchase department in their region.
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Image 3 (67). Illustration of how Denmark is divided by regions. In each region a political council is in charge for all the public hospitals in that area, called the region council. The region council in each region has set up central organizations to maintain
key functions for all hospitals in that area, such as purchase. Purchases from all hospitals in the region is made from a centralized purchasing department, typically located at the largest hospital in the region.
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5. Methods
5.1 Research design
The used research design for this study is based on a sequential exploratory mixed methods research
design, but is not a pure sequential exploratory mixed methods research design. A mixed methods research
design involves combining qualitative and quantitative research. However, that is not exactly what I have
done. But the research design I have chosen to use, have the highest resemblance with the sequential
exploratory mixed methods research design.
The exploratory design is an approach, where the researchers make two separate data collections, where
one type of data can help to develop the other. The design begins qualitatively followed by a quantitative
data collection. Thus, from initial qualitative results, it is evolving and identifying variables for a quantitative
data collection to support the qualitative results. An exploratory design can either be concurrent or
sequential. In concurrent studies, both the qualitative and quantitative data collection is performed at the
same time. In sequential studies, one method is performed before the other. (50)
In this study, a qualitatively data collection is first performed – the literature search. Based on the literature
search, I evolved a deeper understanding of the topic. The deeper understanding was used for the second
part of the research design. But instead of a quantitative data collection, which would be considered
normal in a sequential exploratory mixed methods research design, I conducted several semi-structured
interviews. The decision to make semi-structured interviews was made, because of the ability to divert and
bring up new questions during the interview. In a structured interview, the researcher has a set of
questions which must be rigorously followed. In a semi-structured interview, an interviewguide is prepared
with different topics of interest, but the informant can be asked to clarify and explain in a higher degree. At
the end of the interview, a set of survey-like questions have been prepared, giving it a touch of quantitative
data collection. The initial questions in the interviewguide are made with the purpose of getting knowledge
and information from the informants, while the final survey-like questions are made with the purpose of
getting quantifiable data to support or reject the initial findings made in the literature search.
5.1.1 Literature search
To gather information for this study, a literature search was conducted. The aim of the literature search
was to obtain data about the two innovations, in order to comment on their innovation characteristics. A
secondary outcome of the literature search was to obtain the necessary knowledge, in order to construct
an interview guide for the semi-structured interview.
The literature search was conducted in PubMed, EBSCO and on Google. The used search terms can be
found in table X. Each search term is marked with a quotation symbol (“). The plus sign (+) indicate use of a
Boolean operator, to add a second search term. The Boolean operator, and a second search term, was
necessary in order to narrow down the search result. On PubMed the search term “da vinci surgical
system” alone returned 1628 results, while “gamma knife” returned 17490 results. On EBSCO “da vinci
surgical system” returned 777 results, while the term “gamma knife” returned 3742 results. When
combined with a Boolean operator, the search returned significantly less results. In cases where the result
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was still considered high (in this study >199 is considered high), the first 10 pages (200 studies) was
screened for relevancy. Screening consist first and foremost of reading the title. If the title were deemed
relevant, the abstract was skimmed. If the study was still deemed relevant, it would be saved for possible
later usage.
For the literature search on Google, the same search terms and procedure was used. Google does not
support the use of Boolean operators, but support the usage of symbols instead. By using the quotation
symbol to mark search terms, and the plus sign to add search terms, the same result can be achieved as
using a medical database. On Google the first 3 pages were screened for relevancy under each search term.
In this case, the screening process consisted of reading the metatitle and the metadescription. All relevant
websites was saved for later.
Search terms used in the literature search
Search terms used related to the Da Vinci “da vinci” + “cost comparison” “da vinci” + “cost-effective” “da vinci” + “cost-benefit” “da vinci” + “experience” ”da vinci” + ”advantage”
”da vinci” + ”assessment”
Search terms used related to the LGK “leksell gamma knife” “gamma knife” + “cost comparison”
”gamma knife” + ”assessment” Table 1 - Search terms used in the literature search
Databases used in the literature search including articles found and used
Database Relevant articles found Articles used in the report
PubMed 27 16
EBSCO 15 4
Google 12 6 Table 2 - Amount of literature found and used during the literature search
5.1.2 Interview
In the following section the chosen interview form, themes in the interview and the selection of informants
will be explained.
The interview is a highly relevant form of method in this case. The problem statement indicates a search for
opinions and preferences among a specific population – the decision managers at Danish public hospitals.
In order to obtain the most precise information about that matter, it has been decided to go straight to the
26
source. The chosen interview-form has been decided to be a semi-structured interview. The semi-
structured interview has an informal character, and is a combination of a casual conversation, and a
structured interview. The semi-structured interview is often used, when the interviewer only have one shot
to obtain the interview, and want as much information as possible from the informant. Furthermore, it is
often used when the informants have more knowledge than the interviewer in the area of interest, and the
interviewer doesn’t want to constrain the informant in his answers. (51) To maintain control of the
interview, and ensure important questions are asked, an interviewguide is prepared prior to the interview.
The very first questions of the interviewguide is of introductory character, and primarily serve the purpose
of breaking the ice, and get a conversation going. The rest of the questions are arranged in themes. Three
themes were identified for this interviewguide: The da Vinci robot, the Leksell Gamma Knife and perception
of innovation characteristics.
A minimum of five interviews was desirable in order to cover all regions described in section 4.5. One
interview from an informant from Region Nordjylland, one interview from an informant from Region
Midtjylland and so on until all regions was covered. It was important all regions were covered, in order to
understand what characteristics are emphasized in Danish hospitals, and not only hospitals in e.g. Region
Nordjylland. Besides, there can be differences in the perception of innovation characteristics among
decision managers in different regions. It was decided to target the purchasing department, as they are
responsible for executing the purchase of both Da Vinci’s and LGK’s. In order to schedule the interviews,
emails were sent to all five purchase departments at the end of April 2018. With no answers, a follow-up
email was sent one week later – in the beginning of May 2018. Two interviews were scheduled, and
obtained in week 20 2018. After an additional follow-up by phone two more interviews were scheduled and
obtained in week 21 2018. Only four interviews were conducted, as nobody at Region Sjælland was
available to be interviewed. All four participants were employed in the purchasing department.
All interviews were conducted in Danish, made over the phone, recorded with the app TapeACall, and later
transcribed. It was decided to use standard transcription, because laughs and pauses wasn’t considered
important for the essence of the interview. All interviewees gave oral consent to being recorded, and to be
a part of the report. All informants requested complete confidentiality about their names. Instead of
assigning fictive names, it was decided in compliance with the informants to display the jobtitel.
Interviewguide and letter of consent can be found in tappendix.
6. Results
6.1 Adoption of the innovations
Year Installed Da Vinci’s in the world Installed LGK’s in the world
1970 0 1 (52)
1984 0 3 (52)
1987 0 5 (53)
1991 0 20 (54)
1995 0 63 (55)
1996 0 X
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1997 0 X
1998 0 X
1999 12 (66) 124 (56)
2000 28 (66) X
2001 50 Units (68) 153 (57)
2002 152 Units (69) X
2003 315 Units (69) X
2004 X 202 (58)
2005 394 Units (71) 220 (59)
2006 546 Units (71) X
2007 800 (73) 257 (60)
2008 X
2009 1390 (74) 269 (61)
2010 X
2011 1676 Units (75) 282 (62)
2012 2462 Units (76) 300 (6)
2013 2976 Units (77) 310 (63)
2014 3101 Units (78) X
2015 X X
2016 3729 Units (79) >300 (64)
2017 4271 Units (80) >328 (65) Table 3 - Amount of installed LGK's and Da Vincis worldwide (Installed base)
Image 4 - Development of Da Vinci install base worldwide
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Image 5 - Development of LGK install base worldwide.
29
Image 6 – Development of both Da Vinci and LGK install base worldwide.
6.2 Findings from literature search
In this section the findings made during the literature search, with greatest significance to answering the
problem statement are briefly covered. For a more elaborate review of the findings go to section 4.3 in this
report.
The relative advantage of both innovations is found to be centralized around better treatments. Both
Intuitive Surgical and Elekta claim their product will result in a better outcome for the patient, but research
on the subject can’t endorse the statements without regards. The findings indicate Da Vinci can imply
better patient care in certain procedures (such as prostatectomy), while conventional surgical techniques
would be preferable in other procedures (primarily due to increased cost of using the Da Vinci). The Da
Vinci differs from the LGK by having a high focus on the medical professionals using the innovation. The Da
Vinci claim to decrease variability in surgeon performance, offer better training opportunities and provide
better comfort to the surgeon during a medical procedure.
The compatibility of both the Da Vinci and LGK haven’t been found to be an important characteristic in
terms of rejecting or adopting the innovation.
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Both innovations are complex, and require training before use. The Da Vinci has been found to be intuitive
and easy to learn. The LGK have been found to have a steep learning curve, compared to medical
equipment in general. The functions of the Da Vinci can easily be explained to a non-surgeon, while the
functions of the LGK are difficult to explain to a non-surgeon.
The trialability is considered low for both innovations. In both cases it requires the adoption of an entire
system to test it out in practice, which involves an economical commitment in the million-dollar scale.
Intuitive Surgical can offer surgeons to try a simulator, which can give an indication to the surgeon of
whether or not they like the innovation, and can imagine them using it for performing procedures on a
daily basis.
Three circumstances where the results of adopting the Da Vinci can be observable, has been identified in
the literature. One is the ability to reduce length of admissions for patients. A second is the ability to
prolong the worklife of a surgeon. Some surgeons struggle with musculoskeletal pain caused by bad
posture during conventional surgery. The Da Vinci may possibly increase worklife of surgeons, thus
increasing the active workforce of surgeons. Third circumstance is where people perceive the Da Vinci as a
status symbol and as an indicator of hospital willingness to develop on existing procedures to become
better. It can become prestige to own a Da Vinci. That may imply an increased satisfaction with the
hospital, its management and its doctors from the general population.
6.3 Findings from interview
In this section the most important findings from the interviews related to answering the problem
statement are summarized. The interviews in their full extent have been transcribed and can be found in
the appendix.
When informants were asked about what influenced the decision to adopt the Da Vinci or the Gamma
Knife the answers were quite similar:
It is evident from the interviews, that the entire process of adopting an innovation, such as the Da
Vinci or the LGK, to the Danish public health care sector is a complex process. It involves many
different committees, with representatives in the committees having different professional
Danish: ”.. Det er simpelthen så forskelligt jo. (...)
det er forskellige kriterier der vurderes efter.”
– Informant 3, Birgitte Fjeldgaard
English translation: .. It is so different. (..) There are
different criteria’s to be assessed.”
- Informant 3, Birgitte Fjeldgaard
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backgrounds to cover the greatest aspect possible of the innovation. It is therefore incredibly difficult
for one person to justify what and why the decision was made to adopt the innovation. However,
when the question is approached differently, the informants have no problem highlighting some
important aspects, which were evaluated during the decision process. Especially the relative
advantage, and the subcategories economy, social and performance were mentioned and seemed to
be of great importance in relation to the decision.
Informant 1, Lars Hansen said the following about the Da Vinci:
The relative advantage, or more correctly, the missing relative advantage is obviously of great concern.
Lars Hansen here comments on the economical character and the performance character. Similar to
the findings made during the literature search, the performance (increased patient care) of the Da
Vinci is found to be questionable in the eyes of the adopters. However, several the social character
were identified by Lars Hansen during the interview. First of all, he supported the literature findings
about the Da Vinci prolonging worklife of surgeons by providing better comfort:
Danish: ”en af årsagerne til at det
tilbagevendene er til drøftelse er: punkt 1, at det
er dyrt at anskaffe og drifte, og punkt 2, et er
meget svært at finde evidens på at det rent
faktisk gør en forskel for patienten.”
- Informant 1, Lars Hansen
English translation: ”one of the reasons this is a
recurrent subject to discuss is: 1, the acquisition
cost and running cost is high, and 2, it is very
difficult to find evidence saying it actually does a
difference for the patient.”
- Informant 1, Lars Hansen
Danish: ”den største fordel ved robotter, det er, at man
kan levetidsforlænge, undskyld udtrykket, hvad er det
det hedder, klinikerne. Altså lægerne der står og
operere.”
- Informant 1, Lars Hansen
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And he identified a new relative advantage, also of social character, which couldn’t be identified during
the literature search: The ability to recruit new doctors to the hospital, because of the Da Vinci. Other
hospitals in the region approach Lars, because they need a Da Vinci to their hospital saying it is vital to
attract qualified and competent personnel:
The majority of the informants did not know much about the LGK. The reason why, is because the
purchase of the LGK’s were made outside of the purchase department, and without their involvement.
However, informant 2, a strategic purchaser had some experience in the field of LGK’s. It was
mentioned, that they have decided to go with LINACS instead of Gamma Knifes, because they believe
that technology is improving so rapidly the gamma knife technology may become redundant in the
future.
The following was said:
English translation: ”the greatest advantage of
robots, is the fact that you can prolonge worklife,
sorry the expression, of what is it, the clinicians.
The doctors who stand and operate.”
- Informant 1, Lars Hansen
Danish: ”Det er også noget vi skal ha’, blandt andet
for at kunne rekruttere personale, men også for at
udvikle det faglige område.”
- Informant 1, Lars Hansen
English translation: ”That is also something we need,
among others to recruit personnel, but also to
develop the professional area.”
- Informant 1, Lars Hansen
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When Informant 2 was asked about, if the possible redundancy of the gamma knife technology can
explain the reluctance of potential adopters to adopt the innovation, he said he believed the price to
be a bigger issue:
Danish: ”Spørgsmålet er, om det (red. LINACS) i
virkeligheden er ved at overhale sådan noget som gamma
knife indenom. Altså med stereotaktiske behandlinger,
som er der hvor gamma knife har sin helt store excellence.
Spørgsmålet er om man er ved at nå så langt med de
konventionelle linacs, at man faktisk gør den teknologi
(red. Gamma knifes) overflødig. Vi har jo for eksempel
besluttet os for ikke at købe nogen gamma knife.
- Informant 2, Strategisk Indkøber
English translation: ”The questions is, if the (red. Linacs) in
reality is overtaking something like gamma knife.
Pointedly with stereotactical treatments, which is where
gamma knife have its great excellence. The questions is if
the conventional linacs will make the technology (red.
Gamma knife technology) redundant. For an instance, we
have decided not to buy any gamma knife.
- Informant 2, Strategic Purchaser
Dansk: ”Nej altså, jeg tror for gamma knifes vedkommende
handler det i høj grad om pris.
- Informant 2, Strategisk Indkøber
English translation: ”No, i think in the case of gamma
knife, it is very much a matter of price.
- Informant 2, Strategic Purchaser
34
6.3.1 Rated perception of elucidated innovation dynamics
At the end of every interview, each informant was asked to give the characteristic a rating from 1 to 10
based on perceived importance in the decision phase. The characteristics were based on the findings of the
Da Vinci and the LGK made during the literature search. Region Sjælland did not participate in this rating, as
they were unable to get in touch with.
Innovation dynamic Nord Midt Syd Sjælland Hovedstaden Avg. Score
Economy related to the innovation 7 10 9 X 6 8/10
The innovation is from a well-known brand
4 2 2 X 2 2.50/10
Well documented research can support the claims of effect
8,5 9,5 9 X 8 8.75/10
The innovation is better in terms of patient care than alternative
8,5 10 9 X 10 9.375/10
The innovation is wanted by doctors or nurses
9 10 10 X 9 9.5/10
The innovation is wanted by patients
5 5 3 X 7 5/10
The innovation can coexist with existing equipment
9 10 6 X 5 7.5/10
The innovation is easy to use and easy to understand
6 7 6 X 7 6.5/10
The innovation can be tested in small scale (reduced commitment)
5 6 6 X 8 6.25/10
The innovation imply better reputation
8 8 8 X 8 8/10
Table 4 - Rated perception of innovation dynamics, based on findings made during the interviews
Arranged after perceived importance for successful diffusion and adoption, starting with dynamic
perceived most important:
Innovation dynamic Score The innovation is wanted by doctors or nurses 9.5/10
The innovation is better in terms of patient care than alternative 9.375/10 Well documented research can support the claims of effect 8.75/10
The innovation imply better reputation 8/10 Economy related to the innovation 8/10
The innovation can coexist with existing equipment 7.5/10 The innovation is easy to use and easy to understand 6.5/10
The innovation can be tested in small scale (reduced commitment) 6.25/10 The innovation is wanted by patients 5.0/10
The innovation is from a well-known brand 2.5/10 Table 5 - The rated dynamics arranged after perceived importance, starting with the dynamic perceived most important.
35
7. Discussion
The theoretical framework “Diffusion of innovations” proposed by Everett Rogers, was first time published
in 1962. The initial ideas of Rogers were originally based on farming equipment, which may raise a question
about the relevancy of using his framework on highly advanced surgical equipment, or in today’s health
care industry in general. In the initial phase of this thesis, different studies in the health care sector utilizing
the diffusion of innovations theory were read. (83, 84) Overall the conclusion is the framework is suitable in
the health care sector to evaluate how innovations diffuse and adopt. This claim was supported during the
work with the thesis as well. Ten questions were made and asked during the interview, in order to obtain
adopters perception of certain innovation dynamics. The dynamics were elucidated based on Rogers’
relative advantage, compatibility, complexity, trialability and observability of the Da Vinci and LGK found
during the literature search. One informant said:
Completely independent, and without any knowledge of Everett Rogers, a decision manager at region
Hovedstaden came up with a set of principles for internal use, to evaluate private innovation projects.
Those principles had a significant resemblance to the five innovation characteristics proposed by Rogers,
Dansk: ”Jeg synes faktisk det er nogle rigtigt gode spørgsmål du kom
med her til sidst. De minder rigtigt meget om noget jeg selv skrev
sidste vinter noget vi kalder ”De 7 bærende principper”. Og det er 7
principper der skal kunne tikkes af, for at vi som region siger: Ja, det
her private innovationsprojekt, det er noget vi gerne vil putte penge i.
Og mange af de spørgsmål du stillede før, de kan faktisk kobles
direkte på de her 7 bærende principper. F.eks. med økonomi, klinisk
relevans, skalerbarhed og sådan. Det er lidt sjovt.”
- Informant 2, Strategisk Indkøber
English translation: ”I actually think it is some really good questions
you brought up here at the end. They remind a lot of something I
wrote last winter we call “The 7 bearing principles”. And that is 7
principles that must be checked off, before we as region say: Yes, this
private innovationproject, is something we would like to put money
in. And actually many of those questions you asked before, they can
be linked directly to these 7 bearing principles. For an instance with
economy, clinical relevance, scalability and such. It is a bit funny.”
- Informant 2, Strategic Purchaser
36
which makes the foundation of this project. That indicates to me; the theory proposed by Rogers still is very
much applicable in today’s world. Furthermore, Rogers’ (1) was the foundation of the work made by Mary
Cain and Robert Mittman “Diffusion of Innovation in Health Care” (28), where the innovation
characteristics are discussed in a health care setting. The work by Mary Cain and Robert Mittman was,
together with Rogers, the literary foundation of section 4.3 about innovation characteristics. However,
Mary Cain and Robert Mittman doesn’t call it innovation attributes, or innovation characteristics, but
innovation dynamics. A dynamic can be recognized as a factor that can stimulate, or change a process
within a system. In this case Mary Cain and Robert Mittman described ten dynamics, where four of them
were directly based on the theory made by Rogers. The remaining six are probably the reason why it have
been decided to call them innovation dynamics, and not innovation characteristics, because they are not
directly related to the innovation, but more an influencing factor that can help the innovation diffusion and
adoption process. One dynamic that was recognized as very important in the case of LGK and Da Vinci was
the eight dynamic described by Cain and Mittman; Opinion Leaders.
Opinion leaders are considered credible and respected sources of information. Selection of opinion leaders
is a subconscious process, based on knowledge, attitude, authority and beliefs. Many different opinion
leaders exist, but common to all opinion leaders is the ability to exert influence on others’ decision-making
(85). Opinion leaders in the health care sector are typically individuals, such as well-respected researchers,
and governmental organizations such as the FDA. The opinion leaders have been recognized as key actors
in the diffusion of innovations (28), which also apply to the LGK and the Da Vinci. The LGK have a very slow
diffusion, but in 1987 the first machine in the USA was installed in Pittsburgh – the fifth worldwide. That
becomes an important development in the diffusion of the LGK, due to the research material published
from the University of Pittsburgh Medical Center. It was considered of high quality, honest and believable.
(52, 53). Prior to the installation of LGK in Pittsburgh, the amount of research published about the gamma
knife was scarce. In 1989 followed a FDA approval of the LGK (86). The combination of these two opinion
leaders vouching for the LGK is considered a great influencer to the diffusion. From 1970 to 1987 a total of
five systems were installed worldwide. In 1991, just four years later that number had been increased to 20,
and in 1995 a total of 63 systems had been installed worldwide. The same findings can be made in regards
to the Da Vinci. Since 1998, more than 7,000 peer-reviewed publications have been published (87), and the
FDA approved it in 2000 (88). According to the findings of this study well-documented research is very
important aspect of adopting an innovation. In section 6.3.1, the informants rated it 8.75 on a scale from 1
to 10. That indicates well-documented research is the third most important dynamic, out of all ten asked
dynamics. Informant 4 made a great quote in regards to this finding. When asked about perceived
importance of evidence to support the claims made by the manufacturer on a scale from 1 to 10 she says:
37
Another important aspect of diffusion and adoption is likely to be the complexity of the innovation. The
perceived importance “only” scored 6.5 out of 10, which placed it as the 6th most influential dynamic
among the included dynamics. However, I think the perceived complexity of the innovation may play a
larger role, than what the informants express. During the interviews it became apparent, that the decision
to adopt an innovation to Danish public hospitals is a result of a long and complex process. In the case of
highly advanced surgical equipment, which is considered very expensive, a doctor must first and foremost
apply for the equipment. That application is handed in to a committee responsible for that specific
department, and operates under a budget. That committee typically has a chairman who is a doctor,
accompanied by members with different professions – such as a represent from the purchasing
department, and a technician. That committee will go through the innovation-decision process described in
section 4.4. If it is decided the innovation may be a good idea to adopt, but the price is too expensive to fit
under budget, it will be send to a new committee. That committee is called the apparatus committee, and
has a budget each year to acquire equipment, which can’t be covered by the budget allocated to the
department itself. There is one apparatus committee in each region, which covers all hospitals in that
region. The budget of the apparatus committee varies from region to region, and is determined by the
politicians. When the application arrives at the apparatus committee, they get knowledge about the
innovation, and the innovation-decision process is started over again. The apparatus committee in e.g.
Region Nordjylland (which is the smallest of the regions) only has approximately 40-50 million DKK each
year in budget (approx. 7 million USD). In the apparatus committee a selection of doctors, economists,
engineers and such is sitting. If the innovation is very expensive, the apparatus committee will typically do a
business case on the acquisition, which will be presented for the hospital executives. If the hospital
executives, together with the apparatus committee, estimate the overall costs to exceed what is
reasonable to spend, the innovation can naturally not be acquired. But if the benefits of acquiring the
innovation are deemed great enough, the application can be send from the apparatus committee to the
region council (described in section 4.5). The region council, which consists of 41 elected politicians, is now
imposed to take a decision of whether or not the budget for the apparatus committee should and can be
increased, in order to acquire the innovation. The decision to adopt an innovation has now become a
political decision. In the region council a voting may take place, where each of the 41 members will vote for
Dansk: ”Det er vigtigt. Specielt når vi indkøber nye ting, som
vi ikke allerede har på sygehuset. Så forsøger vi altid at finde
så god dokumentation som muligt. Og det er både fra
forskningsartikler, men også hvad andre sygehuse har gjort
sig af erfaringer. Jeg vil sige 9.”
- Informant 4, Indkøber
English translation: ”It is important. Especially when we
acquire new stuff we don’t already have on the hospital.
Then we always try to find as good documentation as
possible. And that is both research articles, but also
experiences made from other hospitals. I’ll say 9.”
- Informant 4, Purchaser
38
or against. Each vote is equal and independent. That means the 41 politically elected members individually
will go through the innovation-decision process. Members who might not be the best fitted individuals to
evaluate a highly complex health care innovation. We know from the innovation-decision process, that the
first of all serving the right knowledge to the right people is important. The 41 people in the region council
are most likely served the same material, hence served the same knowledge. If the knowledge doesn’t suit
a specific council member, a negative attitude towards the innovation may already have occurred. In the
next stage, the persuasion stage, potential adopters seek information on the subject in order to form an
attitude towards the innovation. If the information found is too difficult to understand, or if the innovation
in general is too complex, the formed attitude is most likely negative. This goes for all committees
evaluating the innovation. For every time a new committee is evaluating the innovation, the chances of
adoption decrease. The same problem wouldn’t occur, if the innovation was very cheap, because it will not
have to go through all mentioned committees. It would most likely be acquired by the department
committee, and purchased with funds from the department budget. Bear in mind some regions may have
minor differences in the structure of their organization, but this is a general depiction based on findings
made in the interviews.
Findings made during the literature search indicate the LGK is perceived as more complex than the Da Vinci.
As seen in section 6.1, the LGK have a significantly slower adoption. Whether or not the complexity is
accountable for that, or it is just a matter of supply and demand remain unknown. It is likely though, the
complexity of the LGK act as a barrier for successful diffusion and adoption, considering the context just
mentioned, and the fact that Europe has the lowest market penetration for LGK’s, mainly due to budget
restrictions imposed by medical authorities (56).
According to the findings in section 6.3.1, the two dynamics were perceived significantly more important
than the others, when it comes to diffusion and adoption of innovations. The two dynamics are the
innovation is wanted by doctors or nurses (scored 9.5/10), and the innovation is better in terms of patient
care than the alternative (scored 9.375/10). These findings are in conformity with findings from a Brazilian
study, where the object was to find drivers of the technology adoption in healthcare. The Brazilian study
elucidated from the findings, that the increased patient care is vital in order to make the hospital consider
the innovation. In order to maintain the system, and avoid discontinuance of the innovation, the doctors
had to like the system. (72)
An unforeseen finding is the fact, that what the patients want isn’t considered to influence the decisions
process a whole lot. The focus is first and foremost to give the patient a good treatment, and make the
work environment good and sustainable. Informant 1 says:
Dansk: ”Det er klart, vi lytter til hvad vores patienter fortæller os, men man
skal også huske på, at de ikke har faglige kvalifikationer til at vurdere en
ehm, altså forstå mig ret. Der bliver lyttet til forslag, det gør der bestemt,
men når vi skal tage en beslutning tænker vi ikke på hvad patienten synes
eller mener. Men forstå mig ret, patienterne er altid i fokus.
Informant 1, Lars Hansen
39
Sources point towards the exact opposite attitude in American hospitals, due to the structure of the health
care system. American hospitals have a higher degree of competition among each other, and need
equipment perceived as top notch in order to attract customers (patients). This is because the American
health care system is based on a Bismarck inspired health care model, where a vast majority of the
hospitals are privately owned institutions fighting for profitability. Acquisitions made by hospitals in the
U.S. do not only need to deliver a good treatment, but also a great perception of the hospital, in the eyes of
the patient. This has been recognized as one of the facilitators for buying Da Vinci’s in the U.S., one study
says: “The reason the hospital purchases the robot is because medicine is competitive” (70). This was
recognized by Intuitive Surgical who launched a direct-to-consumer marketing strategy, in order to create a
need for the Da Vinci in the general population. With an Intuitive Surgical induced patient-perception of the
latest technology is the greatest technology, more and more patients started asking for robotic surgeries in
the U.S. (82), which forced more and more hospitals to buy it in order to maintain customers. Through
marketing, Intuitive Surgical has been able to create a demand for robotic surgery, and a perception of
robotic surgery can provide the best treatment possible. Some surgeons even believe the Da Vinci to have
raised the stature, and given them credibility in their craft (70), even though the evidence to support a
better patient-outcome remains scarce.
It is known, that the Danish health care sector look abroad for inspiration on how to provide better health
care, and among others often look at the U.S. (89, 90). It is not impossible the perceived qualities of the Da
Vinci have travelled across the Atlantic, and been a contributing factor for the diffusion and adoption
process of Da Vinci in Denmark. According to the findings in the interviews, two of the major influencers for
adoption the Da Vinci seemed to be the perceived prestige of owning a Da Vinci, and the increased surgeon
comfort during surgery.
That may lead weaknesses in this study. Perhaps the diffusion and adoption of the Da Vinci is a result of
great marketing efforts, and not really desirable innovation characteristics. Furthermore, it was not
possible to retrieve information about how many Da Vinci’s or LGK’s there were adopted to the Danish
public hospitals. Therefore the worldwide installed base was found in literature for each of the innovations.
An assumption had to be made, that the trend of installed systems worldwide had to be somewhat similar
to the trend in Danish public hospitals.
Some other major weaknesses in this study are based on the study design itself. Innovation studies are
typically qualitative studies, where behavior and opinions of a target group are examined. The preferred
method of choice for innovation studies are typically interviews and surveys (2). The reliance of expert
opinions is inevitable, but has the lowest methodological power according to the hierarchy of scientific
evidence. When performing interviews, bias is almost inevitable. All the interviews were performed over
English translation: ”Clearly, we listen to what our patients tell us, but one
should remember, patients do not have the qualifications to estimate ehm,
don’t misunderstand me. There will be listened to proposals, definitely, but
when we make a decision, we do not consider what the patient think or
mean. Do not get me wrong, the patients are always in focus.
- Informant 1, Lars Hansen
40
phone, which meant the body language and nonverbal cues of the informant couldn’t be read, and isn’t
included in the transcription. That will result in nonverbal bias in the study. Another significant bias, is the
non-response bias. All informants without exception failed to answer the question: “What factors
influenced the decision process”. The missing response is most likely a combination of many factors coming
together: It is a very difficult and complex question, all informants were very busy and had barely time for
an interview, and the answer to that question is very long. In order to elucidate some important factors, or
dynamics, a set of prepared questions was asked. That led to a new bias, the confirmation bias.
Confirmation bias occurs when a researcher search for information, that can either confirm or disprove
preexisting beliefs. When a question was asked, such as: “How important is it the innovation is compatible
and can coexist with existing equipment on the hospital?” a hypothesis of compatibility importance was
either confirmed or disproved. It would be much greater, if the informant said freely, and without getting
influenced, that compatibility is a factor in terms of adoption of the equipment. Due to the inexperience
from the researcher to conduct qualitative studies, anchoring bias cannot be excluded. Anchoring bias is a
tendency to rely too much on the first information given, and not ask further questions about the subject.
Prior to the study a theoretical foundation was established about qualitative studies, in order to conduct
the interviews, but practical experience in the art of performing interviews was limited.
41
8. Conclusion
It is evident from the findings made in section 6.1 that the LGK have a very slow diffusion and adoption
compared to the Da Vinci. Four years after the Da Vinci was introduced to the market, it already had a
higher installed base compared to LGK, even though the LGK had been on the market for more than three
decades. Both through the literature search, and confirmed in the interviews, the most important
innovation characteristic is the relative advantage. Rogers divide the relative advantage into three
subcategories; economic character, performance character and social character. Both innovations have a
weak economic character and are considered very expensive. This was found for both innovations to be a
prohibitive factor for diffusion and adoption. Both innovations claim to have a good performance
character, by increasing quality of treatment given to the patient. This character is without a doubt of great
importance in terms of diffusion and adoption, as it was rated the second most important among all
interviewed decision managers (rated 9.5/10). For the LGK no social character was found, while Da Vinci
seemed very strong in this subcategory. There was found to be an element of prestige in owning a Da Vinci,
it have the possibility to decrease sick-leave at surgeons by providing better comfort, and maybe in
correlation to that, it is a great tool to attract surgeons to the hospital. Overall a lot of social character was
found in the Da Vinci innovation, which all is positively viewed by the doctors. It was found in section 6.1,
that the overall most important dynamic for innovation adoption is, that the innovation is wanted by
doctors and nurses. Perhaps the social character of the Da Vinci plays the largest role in terms of innovation
diffusion and adoption.
Neither compatibility nor trialability was found to be of great influence, when it comes to diffusion and
adoption of innovations in Danish public hospitals. Both systems are individually almost completely
independent of other systems. Generally speaking, it is a relatively important charateristics which the
decision managers do consider (rated 7.5/10), but in the case of Da Vinci and LGK it doesn’t play a key role
in the decision.
The complexity of the innovation was rated 6.25 out of 10 from the decision managers. It plays a role, but it
isn’t a key component in the decision process, according to the interviews. The argument is; if the relative
advantage (primarily patient care) is very good, the complexity doesn’t play a role. There are competent,
highly educated people employed at the Danish hospitals perfectly capable of assessing highly complex
innovations. However, as described in the discussion section, it is not unlikely the decision to adopt an
innovation may end up being indirectly taken by politicians. Particularly if the innovation is so expensive it
may exceed the budget. In that case, the complexity may be very important, as the politicians are
democratically elected people with all sorts of background, and perhaps not fitted to evaluate highly
complex medical innovations. In the literature search, a big difference between the LGK and the Da Vinci
was the perceived complexity. The LGK is perceived very difficult to use and understand, while the Da Vinci
is a complex innovation perceived very easy to use and understand. The difference in adoption pattern
between the LGK and the Da Vinci is not unlikely to be somewhat partly caused by the perceived
complexity.
The observability is likely to play a key role for innovation adoption in Denmark, primarily due to the
political influence. In the interviews it was discovered that Directors want to look good in front of the
politicians, and politicians want to look good in front of the public. All so they can get reelected.
42
9. References
*1+ Rogers, Everett. “Diffusion of Innovations”, 3rd Edition, The Free Press.
*2+ Schneider, M. & Damanpour, F. “Characteristics of Innovation and Innovation Adoption in Public
Organizations: Assessing the Role of Managers”, Journal of Public Administration Research and Theory,
Volume 19, Issue 3, 1 July 2009. Available: https://academic.oup.com/jpart/article/19/3/495/940076 [May,
2018]
*3+ University of Viriginia, School of Medicine. “History and Technical Overview” Available: