Reducing the use of ineffective health care interventions
Key Objective
The NSW Treasury, through the Sax Institute, commissioned CHERE to undertake a literature review of Australian and international models for identifying existing health care interventions that are ineffective, and for reducing the use of these interventions. This is generally described as ‘disinvestment’, and refers to the formal processes and mechanisms which are used to reduce or discontinue the use of selected procedures and treatments.
Results of the project
The review identified a number of case studies and pilot projects. There is limited information available on the mechanisms used, and no rigorous evaluations of their impact. The most developed model is that of NICE which has recently embarked on providing guidance for disinvestment. A number of technologies have been reviewed; but there is limited information available on how these were identified, how disinvestment is implemented, or what the effect has been. There is substantial resistance to any active disinvestment. Across the various case studies, appraisal of candidate technologies seems most likely to be triggered by expert opinion.
Disinvestment is generally passive. Technologies may be removed from funding or reimbursement if new research demonstrating harms or inefficacy becomes public or when a procedure or treatment gradually falls out of use over time. More generally, technologies fall into disuse, and are gradually replaced by new or improved technologies. Even when guidelines or funding rules are changed, there is generally continued use of an existing technology. Active disinvestment has generally been removal of funding for ineffective and/or unsafe technologies, usually initiated by new evidence of inefficacy or harm. There are very few instances of disinvestment, or appraisal for disinvestment, driven by considerations of cost-effectiveness. There are considerable difficulties implementing disinvestment in ineffective health care practices.
An alternative approach to proactive disinvestment of specific technologies is to encourage more rapid change in medical practice. There are various strategies for health care reform which can be categorised as changing provider information, such as through the use of clinical guidelines, or the results of practice variations studies; changing incentives, though different payments for clinicians and other providers, or specifically targeted incentives; changing consumer behaviour, by providing more information with or without financial incentives; or changing the structures of health service delivery to provide organisational support and incentives for more efficient purchasing of care.
A paper based on this work has been accepted for publication in the Australian Health Review.
Funding source
Sax Institute (on behalf of NSW Treasury)
CHERE staff
Gisselle Gallego, Marion Haas, Jane Hall, Rosalie Viney
