Disinvestment. Identifying opportunities for health care disinvestment.

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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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Disinvestment. Identifying opportunities for health care disinvestment.

  1. 1. 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 Health Technology Assessment Unit (UETS), Madrid, SPAINHealth Technology Assessment International Bilbao, 23-27 June 2012
  2. 2. Introduction 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
  3. 3. ObjectivesTo review methods and experiences toidentify and prioritise ineffective healthcare interventionsTo identify health care practices &technologies of uncertain effectiveness,safety and efficiency for disinvestment
  4. 4. Methodology 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
  5. 5. ResultsInternational/national institutionsdisinvestment 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
  6. 6. NICE Integrate disinvestment in clinical agenda Identify interventions no longer effective/worthy Products: Recommendation reminders Criteria to prioritize technologiesTechnology Cost: significant budget impactEffective alternatives of demonstrated cost-effectivenessTechnology elimination may reduce risks to patient safetyDisinvestment impact not target at vulnerable populationTechnologies with small benefits, not life-threatening conditions
  7. 7. NICE800 “Do not do” recommendations databaseType of guidance Interventions NICE “do not do” recommendation Electro-acupuncture should not be used toClinical guidelines Electro-acupuncture treat people with osteoarthritis CG osteoarthritis Glucosamine/ Use of chondroitin/glucosamine products is not chondroitin products recommended for the treatment of osteoarthritis Arthroscopic knee washout alone should not beInterventional arthroscopic knee used as a treatment for osteoarthritis becauseprocedures washout alone it cannot demonstrate clinically useful benefit in the short or long term Abatacept is not recommended for treatment Abatacept of rheumatoid arthritisTechnologyappraisals Abatacept in Abatacept with methotrexate is notguidance combination with recommended for treatment of moderate to methotrexate severe active rheumatoid arthritis whose has responded inadequately to DMARDs
  8. 8. NHS QIPP: Quality, Innovation, Productivity and Prevention PCTs: Croydon List - 34 low value procedures Relatively ineffective procedures Grommet insertion / Tonsillectomy Back pain: injections & fusion Limited evidence of benefits Knee wash outs Potentially cosmetic interventions Aesthetic surgery- breast/ear/nose Incisional/ventral hernias Provision may be inappropriate Minor skin lessions /Varicose veinsEffective interventions with a close Cataract surgerybenefit/risk balance in mild cases Cochlear implants Primary hip replacementService access criteria Knee joint surgeryEffective interventions where cost- Anal procedures Bilateral hip surgeryeffective alternatives should be Carpal tunnel surgerytried first Elective cardiac ablationInitial conservative alternative Hysterectomy heavy menstrual bleeding
  9. 9. Australia 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
  10. 10. Identifying existing non-effective practicesNew evidenceVariationsTechnology developmentPublic interest or controversyConsultationNominationAssess new intervention- displace oldLegacy - GrandfatheringConflict with guidelines Elshaug A et al. MJA 2009; 190: 269-273
  11. 11. Criteria for prioritisation• Cost of service• Impact• Cost-effective alternatives• Disease burden• Sufficient evidence available• Only in research• FutilityElshaug A et al. MJA 2009; 190: 269-273
  12. 12. Other 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
  13. 13. Galician HTA Agency (avalia-t) Methodological guide: obsolete health technologies PriTec tool: application to prioritise potentially obsolete technologies developed by expert panel Domains Criteria Disease frequency: high prevalence/incidence Population/users Burden of disease: mortality, morbidity, disability Technology Use Patients preferences: lower acceptance Efficacy/effectiveness/validity compare alternatives Risk/benefit Adverse effects Risks Efficiency Costs and other Maintenance cost Other implications
  14. 14. 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 Formal DecisionIdentification Prioritisation Assessment Implementation request report plan
  15. 15. Conclusions 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
  16. 16. Thank you for your attention!Contact information:Laín Entralgo Agency, UETS, Madridbeatriz.valentin@salud.madrid.org

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