Disinvestment. Evidence-based disinvestment. Division for Health Care Analysis, Dept. of Medical and Health Sciences, Linköping University: -Center for Medical Technology Assessment (CMT) -National Center for Priority Setting in Health Care -Strategic research area ”Implementation & Learning”. K Roback, J Alwin, A-C Nedlund, L Bernfort

1. Evidence-based disinvestment
June 2012
K Roback, J Alwin, A-C Nedlund, L Bernfort
Division for Health Care Analysis, Dept. of Medical and
Health Sciences, Linköping University
 Center for Medical Technology Assessment (CMT)
 National Center for Priority Setting in Health Care
 Strategic research area ”Implementation & Learning”
____________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

2. Project aim
 Investigate on-going disinvestment
initiatives
 Propose a framework for formal and
active disinvestment in a Swedish
context
 Describe and exemplify through
disinvestment examples
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

3. Overview of the Swedish health system
From: Health Systems
in Transition, 2012

4. Overarching aim of the
Swedish health policy
 “To create social conditions that will
ensure good health, on equal terms, for
the entire population.”
 Includes an affordable healthcare on
equal terms for everyone. But…
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

5. Our work so far
 Literature search to identify on-going
disinvestment initiatives
 Preliminary framework based on the
literature
 Definitions suitable for our study
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

6. What is disinvestment?
The process of withdrawing resources
from existing care practices.
 Stopped or restricted use of healthcare
methods that are:
- harmful
- ineffective
- obsolete
- or not cost-effective
 Stopped or restricted public funding for
previously funded interventions. (Can involve
transfer to out-of-pocket financing.)
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

7. Disinvestment candidate
 An intervention that is either
harmful, ineffective, obsolete or not cost-
effective.
 An intervention that is largely cosmetic or for
other reasons accepted for transfer to private
funding.
Intervention – Indication - Context
 A candidate for disinvestment must be
defined as an intervention-indication pair in a
specified context.
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

8. Elements in a disinvestment
framework (1-4)
1. Scanning for disinvestment candidates.
2. Methods and criteria for selecting
candidates for further evaluation.
3. Methods and criteria for selecting
services to be removed from public
funding.
4. Overarching principles to guide the
disinvestment processes.
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

9. Elements in a disinvestment
framework (5-9)
5. Public and professional involvement in the
process.
6. Transparency of the processes and appeal
procedures.
7. Implementation of the framework.
8. Implementation of disinvestment decisions.
Strategies to achieve changes in practice.
9. Assessment of the impact of completed
disinvestments.
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

10. E1. How to find disinvestment
candidates?
 Types of interventions: diagnostic and
screening, treatments, preventive, assistive
… Medicines, devices, procedures?
 Scanning methods to identify suitable
candidates. Suggestions from public or
professions is a possible element.
 Incentives probably needed
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

11. E2-4. Selecting candidates –
a two-level procedure
Selecting
1. candidates for further evaluation
2. services to be removed from public funding
 Methods and criteria must be specified at both levels
 Decisionmaking through HTA and Health economics
 Ethical principles and legitimacy must be considered
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

12. E5-6. Public involvement
and transparency
How open/accessible should the decisions and the work
processes, decisions and results be?
 Sweden has a tradition of great openness in authority decisions.
When it comes to medical decisions there is still much to do.
 The process must have some public feedback built in, even though
it might slow down the process considerably.
 The complicated nature of these decisions may make it difficult to
inform and engage the citizens.
How politically dependent/independent should the decisions
be?
 Political involvement might lead to integration of public values in
the decisions and to legitimate decisions.

13. E7-8. Implementation
1. Implementation of the framework
2. Implementation of the disinvestment decisions
 Implementation interventions/strategies – a range of methods
for achieving a more evidence based healthcare
 Implementation science, Improvement science, Knowledge to
action, Policy implementation…
Nordic Conference on Implementation of Evidence-Based
Practice, 5-6 Feb 2013, Linköping, Sweden
http://www.imh.liu.se/implementering-och-larande/nordic-conference?l=sv
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

14. E9. Assessment
 Did the disinvestment give the
anticipated results?
 Even if implemented properly a
disinvestment decision may have
unexpected effects.
 “…good health, on equal terms, for the
entire population.”
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden

15. What to do next
 Contact key persons with experiences
from disinvestment
 Analysis of texts and interviews to
evaluate what may work
 Finally – presentation of the framework
and suggested use at the county council
level
Interested persons are welcome to discuss disinvestment
issues with us and/or become our informants.
Please contact: kerstin.roback@liu.se
__________________________________________________________________
Kerstin Roback, Center for Medical Technology Assessment (CMT),
Dept. of Medical and Health Sciences (IMH), Linköping University, Sweden