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, Madridbeatriz.valentin@salud.madrid.org

Thank you for your attention! Thank you for your attention!