Elsevier

Health Policy

Volume 98, Issues 2–3, December 2010, Pages 218-226
Health Policy

Guiding the process of health technology disinvestment

https://doi.org/10.1016/j.healthpol.2010.06.018Get rights and content

Abstract

Objectives

To develop a guideline for health technology disinvestment.

Methods

The Nominal Group Technique was used to determine relevant aspects of disinvestment decision-making. Ideas reaching consensus and previous Spanish guidelines on the acquisition of new health technologies (GANT) and new genetic tests (GEN) structures were used to develop the domains and contents of GuNFT (Guideline for Not Funding Health Technologies). The draft was peer reviewed by local and international experts and their suggestions were incorporated to the first GuNFT version.

Results

Thirty-five ideas reached consensus. The most relevant ones referred to the reasons for disinvesting in a technology and the key aspects that would facilitate disinvestment acceptance. Considering both consensus ideas and GANT and GEN guidelines, the first GuNFT draft was elaborated. After the review process, section numbers and contents were changed. The resulting GuNFT guideline was finally divided into six domains related to: (1) general preliminary recommendations, (2) completing the application form, (3) checking and prioritising applications, (4) assessment, (5) final decision and (6) action plan design. A software was also developed to facilitate GuNFT implementation.

Conclusions

Disinvestment should be a guided process. Accordingly, we present the first guideline for that purpose.

Introduction

Health systems and organisations have to take decisions on the services that are going to be introduced [1]. Unfortunately, some health resources are invested in technologies that are not the most suitable for a given purpose or which might imply a “technical” improvement at a price that does not justify its acquisition [2]. The World Health Organization pronounced that in order to improve the safety and quality of health care it is important to strengthen science-based methods through the assessment of medical technologies and equipment, by establishing requirements in terms of efficiency, quality, safety, profitability, availability and access [3]. Although health technology assessment (HTA) has improved the situation [4], [5], there is still a lack of effective mechanisms to determine the suitability of existing health technologies.

One process that might help to improve the quality of care is based on securing resources through disinvestment in health technologies that “are deemed to be not suitable” and re-investing them in other technologies that met the criteria of safe, effective and cost-effective care. Although this proposal has an obvious logic, in practice, the process presents notoriously thorny scientific, political and ethical challenges [6].

Many organisations have recently recognized the relevance of this problem. On September 2006, the Department of Health of United Kingdom announced a new mandate for the National Institute for Health and Clinical Excellence (NICE) to help the National Health Service (NHS) identify interventions that were not effective [7]. For that purpose, NICE has developed different products, such as cost-saving guidance, costing tools or recommendation reminders [8].

In Australia, the first article about disinvestment in health care was published in 2007 [9]; the same year, the Victoria's Government published a discussion paper about the future directions for health technology uptake, diffusion and disinvestment [10]. Since then, many other organisations such as the Swedish Council on Technology Assessment in Health Care (SBU) [11], the West Scotland NHS [12] and, more recently, the Canadian Agency for Drugs and Technologies in Health (CADTH) [13], [14], have shown interest in this area.

In Spain, health and healthcare are stated as a right by the Spanish Constitution. Since 1981, power on the financing, planning and management of health and health care has been progressively decentralised to each autonomous region, being the Spanish Central Ministry of Health's main tasks the coordination of NHS functions, the development of laws applicable at national level and the international representation.

There are 17 autonomous regions in Spain, each one with its own health care system. This explains why the HTA units have differently evolved and the fact that there are seven HTA agencies in Spain: the Catalan Agency for HTA and Research (AATRM); the Basque Office for HTA (Osteba); the Healthcare Technology Evaluation Agency of the Carlos III Institute (AETS); the Andalusian Agency for Health Technology Assessment (AETSA), the HTA Unit of the Canary Islands (SESCS); the Galician Agency for HTA (Avalia-t) and the Unit for HTA of the Community of Madrid (UETS) [15].

In the Basque Country, the Order of 12 November 2004 states that the managers of the Health Care Services Organisations (Basque Health Service-BHS) should inform the BHS Director about those technologies that are no longer being used. At national level, the Royal Decree 1030 of 15 September 2006 states the potential exclusion of any health technology when: (a) there is evidence of a lack of efficacy, effectiveness or efficiency or an unfavourable risk-benefit ratio; (b) there is no interest in a technology as a consequence of the technological and scientific development or when its usefulness has not been proven and (c) when it no longer fulfils the criteria established in current legislation.

Regarding the abovementioned legislation, a Spanish project entitled “The identification, prioritisation and evaluation of potentially obsolete health technologies” was undertaken in 2008 [16]. This project was lead by two regional HTA agencies (Avalia-t and Osteba) and involved all the Spanish regions. The final results were supposed to be applied to the whole Spanish Health System.

In addition to the project, a guideline was proposed to facilitate the setting of a process to evaluate the potential for disinvestment in certain health technologies or in some of their indications that, whatever the reason is, fail to achieve the objective(s) for which they were originally funded. This paper sets forth this guideline.

Section snippets

Modified Nominal Group Technique

In order to determine the most relevant aspects leading to cease funding an already established health technology, a modified “Nominal Group” Technique [17] was addressed. First, a literature review was conducted finding mainly statement documents or discussion papers from different organisations [6], [7], [10], [11], [12]. Just two articles related to disinvestment were identified [9], [18]. In one of these [9], main challenges of health technological disinvestment processes were classified as

Selected ideas by the Nominal Group

Six criteria attained a final score over 70 points out of 100. Disinvestment should be considered when: (a) there is evidence that the technology causes an overall worsening of health (there is an imbalance between risks and benefits with regard to what it was expected); (b) there is an unacceptable potential risk for the patients or the environment (the safety of the procedure cannot be guaranteed); and (c) the level of discomfort (pain, severe discomfort, etc.) produced by the technology or

Discussion

Disinvestment in health care is a topic of growing international interest, but there is still a lack of guidance on how to conduct the overall process.

Conclusions

To our knowledge, this is the first guideline designing a scenario to disinvest in established health technologies. Nevertheless, further research should focus on the impact of the implementation of the guideline, identifying the problems arising after its use. For that purpose, a monitoring study of the use of the guideline will be conducted in different contexts to identify the barriers and challenges when implementing a disinvestment strategy and, in that case, to modify any step that needs

Acknowledgements

This document has been developed within the collaborative framework stated in the Quality Plan for the National Health System established by the Ministry of Health and Social Policy, under the collaborative agreement signed by the Institute of Health Carlos III, an autonomous Ministry of Science and Innovation body, and Osteba, the Basque Office for Health Technology Assessment of the Department of Health and Consumer Affairs of the Basque Country.

We wish to thank every member of the Nominal

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