Brendon Kearney - HealthPACT: The Lifecycle Of Disinvestment: HealthPACT Report

Disinvestment

A report of a National Workshop

Prof Brendon Kearney

Chair

Health PACT

Disinvestment

Disinvestment relates to the process of withdrawing health resources, either partially or completely, from existing healthcare practices (including procedures, devices, diagnostics, programmes and pharmaceuticals) that are deemed to deliver no or low health gain for their cost, and are thus not efficient health care resource allocations. Released resources can then be reinvested in clinical practices and technologies that deliver safe and effective healthcare for all patients, therefore representing efficient health resource allocation

Passive Disinvestment and natural

attrition

Many interventions become outmoded

e.g. Diagnostic ERCP

Epoetin β

Pegfilgastrin

Tonsillectomy

Appendicectomy

Active Disinvestment

Active strategies used in a more directive

approach to reduce the practice of

unnecessary, ineffective, inefficient or

harmful interventions

Challenges

• no agreed disinvestment methodology

• resources to disinvest

• difficulties with identifying low value services

• multiple stakeholders

• interest groups – clinicians, industry, patients

• clinical practice change

• high QALY

• clinical guidelines

• measureable outcomes

Identifying and prioritising

disinvestment opportunities

Top down • high cost clinical practices and technologies

• low volume clinical practices

• surgical substitution

• potential targets for clinical redesign

Bottom up • stakeholder engagement particularly clinicians

• evidenced based assessment of quality and safety of clinical practices

• investment in new technologies should drive a review of disinvestment of comparators

• assessment of variation in practice e.g. Wennberg methology

Stakeholder Engagement

Australian Government Comprehensive

Management Framework

- Review of MBS

ophthalmology – clinician and patient groups

gastroenterology

New Zealand National Health Committee

- Reprioritisation involves early stakeholder

consultation

Stakeholder Engagement

Health PACT

- Tavi, Renal Nerve Denervation

Queensland Health

- Selecting the most appropriate and relevant tests and treatments (SMARTT)

Clinical working groups identify and make recommendations

Choosing Wisely – USA

- Lists developed with special societies

20 groups developed 5 topics each

Evidence Based Approach

• Focus on safety and quality

• Focus on evidence rather than cost saving

• ASTUTE study - B12/folate testing

• NICE – identified low benefit clinical

interventions

• Registries

Continued investment as a driver of disinvestment

Ability to reinvest savings

Life cycle

System efficiencies

Safety and quality

Vic Health - Return on investment

Topics

Astute Study – B12/folate testing

– Comprehensive management framework – 22

MBS to be reviewed by MSAC.

Ophthalmology, colonoscopy, bariatric

surgery, pulmonary catheterisation

– Focal therapy for prostate cancer

– Choosing wisely – New Zealand

• Grommots

• Catheter ablation for AF

Topics

– Choosing wisely – Victoria – NICE

Review of formulary

– protun pump inhibitors

– ACE inhibitors

– Statins

Auckland – DHB • Home humidification

• MRI monitoring of acoustic neuromas

Key messages

• The engagement of, and timing of consultation with the clinical community, is paramount to ensure appropriate consideration and successful withdrawal or acceptance of restricted use of a technology or clinical practice

• In identifying and prioritising technology or clinical practice disinvestment consideration, evidence of quality and safety issues is a key level to engage clinicians

• There may be a lack of robust evidence for the appropriate disinvestment of established, long-term healthcare practice and technology, however, a lack of evidence does not equate to evidence of a lack of effectiveness

• Evidence alone is not sufficient and “people, structures and values need to be assessed”

Key messages

• Local health technology committees are integral, not only the introduction of new technology or clinical practice, but also for identifying opportunities to reassess evidence, including quality and safety of existing technology or clinical practice to ensure optimal health care

• Clinical redesign encourages health services to monitor high-cost diagnostic-related groups, costs and benchmark outcomes for disinvestment opportunities and use redesign processes to improve the patient journey and eliminate waste

• Patient benefits and non-financial metrics are just as important as clinical outcomes to communicate in any disinvestment activity

• Increasing system capacity, freeing up system resources and incentivising a proposed change in clinical practice are examples of successful disinvestment activity outcomes