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Identifying opportunities for health care disinvestment. Experiences and methods review. Valentín-López B, Fernández de Larrea N, Callejo-Velasco D, López-Pedraza MJ, Maeso-Martínez S, Blasco-Amaro JA.
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Identifying opportunities for health care disinvestment
Identifying opportunities for health care disinvestment
Valentín-López B, Fernández de Larrea N, Callejo-Velasco D, López-Pedraza MJ, Maeso-Martínez S, Blasco-Amaro JA
Experiences and methods reviewExperiences and methods review
Health Technology Assessment Unit (UETS), Madrid, SPAIN
Health Technology Assessment International Bilbao, 23-27 June 2012
Disinvestment: withdrawing existing
health care resources that provide little
clinical value for money
Opportunity for reinvestment resources in
cost-effective interventions
Sustainability of health care system-
increase delivering effective treatments
IntroductionIntroduction
ObjectivesObjectives
To identify health care practices &
technologies of uncertain effectiveness,
safety and efficiency for disinvestment
To review methods and experiences to
identify and prioritise ineffective health
care interventions
MethodologyMethodology
Literature review
Databases: HTA CRD, Cochrane, Medline, ISI wok
Institutions: NICE, NHS, HTAi, SHTG, AHRQ
Key words: disinvestment or obsolete or ineffective
Inclusion/exclusion criteria
Methods, criteria and global experiences of
disinvestment were included
ResultsResults
International/national institutions disinvestment experiences
NICE: “do not do” recommendations
Croydon list: low value interventions
Australia: framework identifying practices
Canada: disinvestment obsolete practices
Scotland: radical service redesign
USA: comparative effectiveness research
Spain: obsolete technology/GunNFT
NICENICE
Integrate disinvestment in clinical agendaIdentify interventions no longer effective/worthy
Technology Cost: significant budget impact
Effective alternatives of demonstrated cost-effectiveness
Technology elimination may reduce risks to patient safety
Disinvestment impact not target at vulnerable population
Technologies with small benefits, not life-threatening conditions
Products: Recommendation reminders
Criteria to prioritize technologies
NICENICE
800 “Do not do” recommendations database
Type of guidance Interventions NICE “do not do” recommendation
Clinical guidelines
CG osteoarthritis
Electro-acupuncture
Glucosamine/chondroitin products
Electro-acupuncture should not be used to treat people with osteoarthritis
Use of chondroitin/glucosamine products is not recommended for the treatment of osteoarthritis
Interventional procedures
arthroscopic knee washout alone
Arthroscopic knee washout alone should not be used as a treatment for osteoarthritis because it cannot demonstrate clinically useful benefit in the short or long term
Technology appraisals guidance
Abatacept
Abatacept in combination with methotrexate
Abatacept is not recommended for treatment of rheumatoid arthritis
Abatacept with methotrexate is not recommended for treatment of moderate to severe active rheumatoid arthritis whose has responded inadequately to DMARDs
NHSNHSQIPP: Quality, Innovation, Productivity and Prevention
PCTs: Croydon List - 34 low value procedures
Relatively ineffective procedures
Limited evidence of benefits
Grommet insertion / TonsillectomyBack pain: injections & fusionKnee wash outs
Potentially cosmetic interventions
Provision may be inappropriate
Aesthetic surgery- breast/ear/noseIncisional/ventral herniasMinor skin lessions /Varicose veins
Effective interventions with a close benefit/risk balance in mild cases
Service access criteria
Cataract surgery Cochlear implantsPrimary hip replacementKnee joint surgery
Effective interventions where cost-effective alternatives should be tried firstInitial conservative alternative
Anal proceduresBilateral hip surgeryCarpal tunnel surgeryElective cardiac ablationHysterectomy heavy menstrual bleeding
AustraliaAustralia
Since 2009 - Formal Agenda
HTA Agencies role in making recommendations
Explicit criteria for removing drugs
Disinvestment practices related to safety concerns
ASTUTE Health Study
ART women over 42y/Upper airway surgical procedures for OSA
Framework to identify and prioritize practices for
assessment
Elshaug A et al. MJA 2009; 190: 269-273
New evidence
Variations
Technology development
Public interest or controversy
Consultation
Nomination
Assess new intervention- displace old
Legacy - Grandfathering
Conflict with guidelines
Identifying existing non-effective practicesIdentifying existing non-effective practices
• Cost of service
• Impact
• Cost-effective alternatives
• Disease burden
• Sufficient evidence available
• Only in research
• Futility
Elshaug A et al. MJA 2009; 190: 269-273
Criteria for prioritisationCriteria for prioritisation
Other experiencesOther experiences
Canada “Delisting” activities – insurance plans
Disinvestment obsolete practices
Macro level: Program Budgeting & Marginal Analysis
Scotland – SHTG Systematic policy approach – service redesign
Sentinel procedures: tonsillectomy, grommet insertion…
USA – IOM Comparative effectiveness research
Clinical evaluations of alternative interventions
Galician HTA Agency (avalia-t)Galician HTA Agency (avalia-t)
Methodological guide: obsolete health technologies
PriTec tool: application to prioritise potentially obsolete technologies developed by expert panel
Domains Criteria
Population/users
Disease frequency: high prevalence/incidence
Burden of disease: mortality, morbidity, disability
Technology Use
Patients preferences: lower acceptance
Risk/benefit
Efficacy/effectiveness/validity compare alternatives
Adverse effects
Risks
Costs and other
Efficiency
Maintenance cost
Other implications
Basque Office for HTA (Osteba)Basque Office for HTA (Osteba)
Guideline for Not Funding Technologies (GuNFT) Nominal group: Clinicians, Managers, HTA researchers
Criteria for not funding technologies
Imbalance on risk/benefits
Potential risk of technology
Technology not accepted among patients
Strategies to facilitate disinvestment:
information and involvement
Establish disinvestment steps
IdentificationFormal request
Prioritisation AssessmentDecision report
Implementation plan
International/national institutions have implemented disinvestment experiences
Few formal methods or processes for identifying ineffective or inefficiency health care interventions
Active disinvestment: removal to reallocate interventions of clinical value
Passive disinvestment: changes in practice and interventions redesigned
ConclusionsConclusions
Contact information:Laín Entralgo Agency, UETS, [email protected]
Thank you for your attention! Thank you for your attention!