The challenge of disinvestment.

The challenge of disinvestment

Kalipso Chalkidou

Research and Development

NICE

ESRC Seminar Series; March 2007

Good intentions

• “With all the excellent developments in medicine that are becoming available, it is not in anyone's interest to waste money on treatments that do not provide good value for money […] NICE is going to provide authoritative advice to help us make the best use of the resources available to the NHS.”

Frank Dobson, Secretary of State for Health, speech launching NICE, March 1999

• ACTS Definitions and Criteria: “Does the proposed guidance relate to one or more interventions which could, without detriment to patient care, be used more selectively, thus freeing up resources for use elsewhere in the NHS?”


Limited impact?

• There are some good examples: – appraisals on the removal of wisdom teeth and proton pump

inhibitors;

– guidelines on the management of heavy menstrual bleeding, caesarean section and LARC

but…• Clear bias in favour of new technologies • Few “disinvestment” topics actually referred to NICE• Rationale for referral not explicitly stated in the guidance remit• Limited evidence base for established treatments• Resistance to withdrawing existing technologies


•National tariff uplift 2005/06: £389m (+0.9%) •Specific adjustments to HRGs

approx £800-1,200m overall impact

Waste not, want not

• “NICE should be

asked to issue guidance to the NHS

on disinvestment, away from established

interventions that are no longer appropriate

or effective, or do not provide value for money.”CMO Annual Report, 2005

• "NICE has an excellent track record in identifying and recommending the most effective new treatments. But we need to ensure that we balance this with better advice on unnecessary and ineffective interventions that can be stopped." Andy Burnham, Sep 2006


Can cost inflating be cost-effective?

1. Develop cost-effective public health guidance: reduce clinical need: “fully engaged scenario”

2. Set realistic threshold reflecting ICERs of services currently introduced or discontinued at the local level, assuming a rational prioritisation process, informed by economic evidence, exists

3. Identify, evaluate and recommend against ongoing cost-ineffective practices: set up a disinvestment agenda

4. Influence strategic research priorities to reduce uncertainty and prevent decision reversal and sunk costs


NICE disinvestment activities

• Recommendation reminders• Commissioners’ guides • Using existing NICE programmes• Establishing dedicated disinvestment streams• Topic selection• A disinvestment related research agenda• Working with external partners


Recommendation Reminders

• Existing NICE guidance• Still relevant to the NHS: clinical expert input• Additional costing tools• Over 250 single “do not do” recommendations between 1999-

2005

• Lesson 1: the press release matters!• Lesson 2: baseline hard (impossible?) to define; lack of data• Lesson 3: some people do not want to be reminded…


Commissioners’ Guides

• Not dedicated disinvestment tool• Aimed at supporting evidence-based effective commissioning• Building on NICE costing tools/budget impact analysis• Examples: upper GI endoscopy, foot care for diabetes,

anticoagulation, management of COPD• Commissioning guides are not:

– advice on how to commission

– new formal NICE guidance

– fixed: can be adjusted to local setting

• Web-based; accessible to PCTs and practices in England


Topic selection

• Increased responsibility of NICE in topic selection• No separate disinvestment consideration panel• Consider:

– variation in practice,

– current usage and potential real savings,

– substitute technology/pathway,

– feasibility of change in practice,

– effect on inequalities(?)

• Sometimes, disinvestment topics result in investment recommendations…


Using existing NICE programmes

• Target wasteful practice at the scoping stage• Encourage guidance developers to think about waste• Improve communication of “do not do” recommendations• “PET, structural MRI, magnetic resonance volumetry and

magnetic resonance spectometry should not be used in the differential diagnosis of parkinsonian syndromes, except in the context of clinical trials.” Parkinson’s disease, NICE Clinical Guideline, London, June 2006

• “The use of multi-channel cystometry, ambulatory urodynamics or videourodynamics is not recommended before starting conservative treatment.” The management of urinary incontinence in women, NICE Clinical Guideline, London, October 2006


New disinvestment streams

• Same methodology of economic evaluation• Focus on identification of relevant topics• Key areas:

– Service reconfiguration – but the evidence base is different

– Inappropriate use of antibiotics: chloramphenicol for conjunctivitis, tetracyclines for acne and topical corticosteroid/antimicrobial combinations

– Grommets

– Diagnostic tests


Research and disinvestment: atopic eczemaWhat we said:

• It is recommended that topical corticosteroids should be prescribed for application only once or twice daily.

What we do not know:

• Is once-daily use of the older twice-daily products equivalent to the once-daily-only products of the same potency?

What we said:

• Topical tacrolimus and pimecrolimus are not recommended for the treatment of mild eczema or as first-line treatments for eczema of any severity.

What we do not know:

• What are the long-term effects of tacrolimus and pimecrolimus?• How do these drugs compare with appropriate potencies of

topical corticosteroids?ESRC Seminar Series; March 2007

Cooksey Report

• “The Review recommends that funding be identified and formal arrangements be established between NHS R&D and NICE in order to implement NICE recommendations calling on the NHS to use health interventions in a research context”– Value-based pricing for new technologies– Continuous evaluation through registries and databases for

established treatments– Implementation of public health and clinical guidelines

recommendations “only in research”– Methods for developing disinvestment guidance


Partner organisations

• Cochrane Collaboration • Association of Public Health Observatories• NHS Institute • NHS information centre and other databases• Welsh HIRU• …


The challenges of substitution


Evidential and methodological…

• Selecting the right topics• What is the comparator?• Weak evidence base for established treatments • Guidance developers reluctant to stop current practice • No “sponsor” and little incentive for more research• Are savings real(isable)?

– Economic vs costing model; defining opportunity cost– Extrapolating over long time horizons– Establishing the baseline


Implementation…

• What happens with the savings: Choosing Health vs chemo?

• The “kinkiness of the SW quadrant”

NICE-specific• Centralised advise often insensitive to local setting• NICE does not look at everything; what about

activities below the baseline?


and other!

• Single technology appraisal: getting the comparator/timing right

• Substituting new technologies for preventative interventions: lowering the threshold?

• 3 month implementation directive and the health-wealth trade-off


Way forward

• NICE can: – Help manage pressures – Trigger a public debate and help bring about a mentality change– Encourage necessary research and evidence generation – Produce more evidence-based disinvestment advice and less

budget-inflating recommendations

But we can do more…


How can NICE really add value?

• Empower commissioners and consumers (PCTs, GPs…patients)• Provide access to:

– evidence-based

– need-adjusted

comparative rates for benchmarking • Elicit patient and professional input• Move away from centralised intervention-specific “do not do”

guidance– commissioners' guides

– tailored guidance (?)

– evidence base for “contract exclusion” agenda (?)


It’s the data,…!

NICE guidance

surgery drugs diagnostics disease management prevention health promotion

Gu

idan

ce develo

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ent stag

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1. Topic selection

2. Scoping

3. Guidance development

4. Evidence gaps

5. Budget impact

6. Implementation support

7. Guidance review

8. Guidance uptake and impact assessment

BoD, variation, evidence base, trend data

Prevalence/incidence, current practice, comparators

Baseline risk, resource use, QoL, long-term follow up, subgroup analysis, generalisability of effect…

Ongoing studies, “only in research” when high uncertainty, high priority research questions

Unit costs, PCT/SHA demographics, service activity, prescribing and workforce data

Examples of good practice, existing networks, relevant policy initiatives

New evidence on long term costs, efficacy, safety, alternatives

Prescribing (by indication) and activity data, barriers, frontline substitution threshold, relating spending to health outcomes

Lack of data…still useful?

• Evidence of lack of effectiveness vs lack of evidence of effectiveness:– Inform strategic

research priorities– Support

commissioning


CEA in the NICE context is not a panacea…We need access to longitudinal data on variation* coupled with

robust local prioritisation processes*Fisher et al, Ann Intern Med, 2003; Skinner et al, Health Affairs, 2006

“NICE has operated during the halcyon days of an unprecedented period of sustained growth in the overall NHS budget, a rate of growth that cannot continue indefinitely. When budgets cease to grow, a new day will dawn for NICE and the NHS as they manage the delicate balance between cost-effective new technologies and local health authority budgets.”

Pearson and Rawlins, JAMA, November 2005


Thank you!


The challenge of disinvestment.

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