This document reviews methods and experiences with health care disinvestment. It identifies several international institutions that have implemented disinvestment recommendations or lists of low-value practices. These include NICE in the UK, which has an online database of over 800 "do not do" recommendations, and initiatives in Australia, Canada, and Scotland. The document also describes criteria used by these organizations to prioritize health care interventions for disinvestment based on factors like costs, benefits, and availability of alternatives. Overall, the review finds that while few formal methods exist, disinvestment can help reallocate resources to more effective interventions and improve sustainability of health systems.

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, SPAIN
Health Technology Assessment International
Bilbao, 23-27 June 2012

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. Objectives
To review methods and experiences to
identify and prioritise ineffective health
care interventions
To identify health care practices &
technologies of uncertain effectiveness,
safety and efficiency for disinvestment

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. Results
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

6. NICE
 Integrate disinvestment in clinical agenda
Identify interventions no longer effective/worthy
 Products: Recommendation reminders
 Criteria to prioritize technologies
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

7. NICE
800 “Do not do” recommendations database
Type of guidance Interventions NICE “do not do” recommendation
Electro-acupuncture should not be used to
Clinical 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 be
Interventional arthroscopic knee used as a treatment for osteoarthritis because
procedures washout alone it cannot demonstrate clinically useful benefit
in the short or long term
Abatacept is not recommended for treatment
Abatacept of rheumatoid arthritis
Technology
appraisals Abatacept in Abatacept with methotrexate is not
guidance combination with recommended for treatment of moderate to
methotrexate severe active rheumatoid arthritis whose has
responded inadequately to DMARDs

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 veins
Effective interventions with a close Cataract surgery
benefit/risk balance in mild cases Cochlear implants
Primary hip replacement
Service access criteria Knee joint surgery
Effective interventions where cost- Anal procedures
Bilateral hip surgery
effective alternatives should be
Carpal tunnel surgery
tried first Elective cardiac ablation
Initial conservative alternative Hysterectomy heavy menstrual bleeding

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. Identifying existing non-effective practices
New evidence
Variations
Technology development
Public interest or controversy
Consultation
Nomination
Assess new intervention- displace old
Legacy - Grandfathering
Conflict with guidelines
Elshaug A et al. MJA 2009; 190: 269-273

11. Criteria for prioritisation
• 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

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. 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. 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 Decision
Identification Prioritisation Assessment Implementation
request report
plan

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. Thank you for your attention!
Contact information:
Laín Entralgo Agency, UETS, Madrid
beatriz.valentin@salud.madrid.org