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Withdrawal of technologies of low added value

Country: 
Spain
Partner Institute: 
University of Barcelona
Survey no: 
(15) 2010
Author(s): 
Iaki Gutirrez Ibarluzea; Nora Ibargoyen Roteta; Gaizka Benguria Arrate; Lorea Galnares Cordero; Jos Asua Batarrita;
Health Policy Issues: 
Pharmaceutical Policy, Long term care, System Organisation/ Integration, Political Context, Funding / Pooling, Quality Improvement, Benefit Basket, Access, Remuneration / Payment, Responsiveness, HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes yes yes yes yes no

Abstract

Disinvestment in health technologies that "are deemed to be not suitable" and reinvesting the resources in other health technologies that meet the criteria of safe, effective and cost-effective care might help to improve the quality and efficiency of care. Unfortunately, experience in the Basque and Galician autonomous regions and in Australia and UK shows that this is a difficult process partly due to the lack of reliable administrative mechanisms to identify and prioritise health technologies.

Purpose of health policy or idea

To facilitate the establishment of an adequate process, in other words: a transparent, systematic and explicit process to assess 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 financed.

Main points

Main objectives

The main objectives can be found in the document of reference (Ibargoyen-Roteta et al, 2010, available at http://www.osanet.euskadi.net/osteba/es) and are as follows:

  1. Take into account not only the economic aspects of the disinvestment process but also the different factors that influence the process.
  2. Improve the efficiency of the health services offered.
  3. Design a process that can be adapted to the local context.
  4. Ensure not only the "removal" (or replacement) of health technologies of less benefit to patients in terms of safety and effectiveness, but also those that are of less benefit in terms of their quality of life, those that are more invasive or those that have increased costs for the patient.
  5. Ensure that the process takes into account the services offered by the Centre, the National Health Service or equivalent, to make sure that disinvestment does not leave an undesired gap in the affected service.
  6. Ensure that all health professionals take part in the process (in the identification process and/or the assessment process).
  7. Take into consideration the importance of disseminating the decision in an adequate manner ensuring the transparency of the process. This includes providing the rationale for the decision and the strategy the Hospital or implicated Health Services have drawn up to enforce the decision.
  8. Ensure that any action deriving from this process will ultimately be of benefit to patients or the population more broadly.

Type of incentives

The incentives are related to the obtention of funds for re-investment or investment on innovations of higher added value.

Groups affected

Policymakers, Healthcare managers, Clinicians, biotechnological and pharmaceutical companies, patients

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent system-dependent system-neutral

The proposal is rather innovative, because the idea of delisting technologies is not new but the way of facing the problem is innovative. The degree of consensus obtained to establish the process has been high and the the impact both structural and systemic is fundamental. The public visibility could be high if the process is fully established due to the need to inform the different stakeholders, including patients and society and making the process accountable, measurable, credible and specific. Regarding the transferability, this kind of process can be established in any context, but the tool itself defines mechanisms to make tailored interventions rather than "one fits all" ones. The Health system and its characteristics will define the role of each stakeholder in the process, although guidance on how to proceed is suggested.

Political and economic background

This new policy has been included in an overall process for the introduction and withdrawal of health technologies in the Basque region and will be included in a similar process for the definition of a common health package in the Spanish Health System.

At the Spanish context and especially in the case of Galician and Basque Autonomous regions, legislative mechanisms were already in place, both for the introduction of new and emerging technologies and for considering the withdrawal of superseded technologies. Nonetheless, practical mechanisms and tools similar to those established for new technologies had to be established for the withdrawal of technologies.

Change based on an overall national health policy statement

The current policy is in line with the actions that have been defined for the sustainability of the Basque-Spanish Health Systems. It is an opportunity for obtaining funds for innovation and a way to make the process more transparent and accountable.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no yes yes yes yes yes no

Origins of health policy idea

The idea has been a common approach by different Health Technology Assessment agencies and academia, principally from Spain, Australia and the UK. The main purpose of the idea is to include in the health care system only those technologies of proven added value. There have been different approaches. In Spain, a methodological guideline for the assessment of obsolete health technologies has been developed by the Galician Agency Avalia-t. Osteba, the Basque Office for HTA, has developed a guideline for structuring the decision-making process when a technology has a potential for being withdrawn or delisted from the benefit package or the provision. This Basque guideline has been introduced in the overall process of introduction of new and emerging technologies in the Basque Health System. It will help in a previously established regulatory law for the management of health technologies in the common benefit package.

Initiators of idea/main actors

  • Government
  • Providers: Overall, in the Spanish Health System, various providers have stated their interest and their aim to colaborate in the process and to include both guidelines and software in their processes of introduction and withdrawal of technologies
  • Patients, Consumers: Patients are one of the main actors in this process and that is why they should be included
  • International Organisations: An interest subgroup on disinvestment has been established in the HTAi society.
  • Opinion Leaders: Some scientific opinion leaders have also supported the idea of disinvestments and are establishing similar processes in other countries.
  • Others: Clinicians and members of the identification of new and emerging health technologies networks of the Basque Health Service, mainly health professionals and managers are suporting the idea and has found the process as an opportunity for health innovation

Approach of idea

The approach of the idea is described as:
new: Although the concept of obsolete technology was defined some years ago, no reliable mechanisms were established to delist technologies and inform health managers, clinicians and society on the implications of these mechanisms.

Innovation or pilot project

Local level - There is an established program for the introduction of a Guideline for not Funding Technologies (GuNFT guideline) and a software in the Basque Health Service Hospitals.
Within institution - There is an agreement between HTA agencies for the implementation of the process in the Spanish Health System.
Pilot project - A pilot project for testing the Guideline for not Funding Technologies (GuNFT) has been agreed with different hospitals in Spain and the UK (North West region, Manchester).

Stakeholder positions

Other stakeholders and affected groups have started to work in the same field but from the perspective of the identification of technologies of low added value and what the delisting processes could produce in the health systems and the reactions that could be obtained from the establishment of those processes. Similar approaches have been proposed in the case of UK (NICE) and Australia (AHTA).

Actors and positions

Description of actors and their positions
Government
MoH and Consumer Affairs of Basque Regionvery supportivevery supportive strongly opposed
Spanish MoH and Social Policyvery supportivesupportive strongly opposed
Galician Region MoHvery supportivesupportive strongly opposed
Providers
Clinic Hospital Innovation Unitvery supportivevery supportive strongly opposed
Valme Hospital Quality Unitvery supportivevery supportive strongly opposed
Virgen del Rocio Hospital Subdirectoratevery supportivevery supportive strongly opposed
Miguel Servet Hospital Technology Assessment Unitvery supportivevery supportive strongly opposed
Basque Health Service Provision Managersvery supportivesupportive strongly opposed
Patients, Consumers
Eurordisvery supportivesupportive strongly opposed
ISG of HTA on patientsvery supportivesupportive strongly opposed
International Organisations
ISG on disinvestment of HTAivery supportivevery supportive strongly opposed
Health Cluster netvery supportivesupportive strongly opposed
Opinion Leaders
Adam Elshaugvery supportivevery supportive strongly opposed
Sarah Gardnervery supportivevery supportive strongly opposed
Steve Pearsonvery supportivevery supportive strongly opposed
Health Technology providers
SorTek and ZaharTek networks of expertsvery supportivesupportive strongly opposed

Influences in policy making and legislation

In the case of the Basque Country the legislation was already in place, but there were no mechanisms to produce the results stated in the legislation. Also, there has been no guidance on how to promote and structure the process and what the role of the different stakeholders should be. In fact, managers and clinicians had no knowledge of the legislation and its implications on the sustainability of the health systems. The idea of "one technology in and one out" was implicit, but no methodological approaches were developed to face the aforementioned process.

Actors and influence

Description of actors and their influence

Government
MoH and Consumer Affairs of Basque Regionvery strongvery strong none
Spanish MoH and Social Policyvery strongstrong none
Galician Region MoHvery strongstrong none
Providers
Clinic Hospital Innovation Unitvery strongvery strong none
Valme Hospital Quality Unitvery strongvery strong none
Virgen del Rocio Hospital Subdirectoratevery strongvery strong none
Miguel Servet Hospital Technology Assessment Unitvery strongvery strong none
Basque Health Service Provision Managersvery strongstrong none
Patients, Consumers
Eurordisvery strongstrong none
ISG of HTA on patientsvery strongstrong none
International Organisations
ISG on disinvestment of HTAivery strongvery strong none
Health Cluster netvery strongstrong none
Opinion Leaders
Adam Elshaugvery strongvery strong none
Sarah Gardnervery strongvery strong none
Steve Pearsonvery strongvery strong none
Health Technology providers
SorTek and ZaharTek networks of expertsvery strongstrong none
MoH and Consumer Affairs of Basque Region, Clinic Hospital Innovation Unit, Valme Hospital Quality Unit, Virgen del Rocio Hospital Subdirectorate, Miguel Servet Hospital Technology Assessment Unit, ISG on disinvestment of HTAi, Adam Elshaug, Sarah Gardner, Steve PearsonSpanish MoH and Social Policy, Galician Region MoH, Basque Health Service Provision Managers, Eurordis, ISG of HTA on patients, Health Cluster net, SorTek and ZaharTek networks of experts

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The successful implementation of the framework described in this proposal depends, in turn, on a number of different factors that must be taken into consideration:

  1. The use of this approach on a regional-national level should be accompanied by giving consideration to those technologies for which disinvestment can not be considered at a local level (due to the complexity of the technology or the coverage of the technology). Nevertheless, it should be noticed that this process can also be used at a hospital level, because it could assist the assessment of locally used technologies, aiding the hospital to reorganize its resources.
  2. It would be advisable to integrate this framework, if any, with both the procedure used to identify new and emerging technologies and the one used to monitor technologies in use.
  3. If there is not an existing health technology assessment committee or similar group, it is recommended that one is established. Written rules should specify the method by which consensus is going to be reached, and the level of authority the Committee is going to have, should be agreed.
  4. Participation of health professionals with the appropriate knowledge (EBM, statistics, HTA, management or health economics), skills and attitudes in this process must be encouraged, bearing in mind that they must have sufficient time to dedicate to this task.
  5. It is essential to establish a working procedure familiar to all the professionals of the health organization, and to have the commitment of the management team of the centre or the final decision maker to accept the defined working method.
  6. It is advisable to develop the procedure by electronic means, for example, by facilitating the location of instructions, forms and other documents required to formulate GuNFT applications in the net. The process would be most efficient if the net is used to send applications to the assessment committee and for the committee to issue its decision. In this way, it would be possible to speed up administrative procedures and waiting time would be reduced. It is also advisable to secure the commitment of the organisation to minimise the time that elapses between the request, the recommendation of the committee and the final decision of the management team. All these factors are important in order to reduce health professionals' negative perception of bureaucratic barriers.
  7. Once the decision to disinvest in a specific technology has been taken, it is necessary to design an "action plan" in order to ensure that the process is followed in the most adequate manner, underlining the importance of informing health professionals and the patients affected about the decision taken, the reasons that have led to it and the actions that are going to be performed.

Monitoring and evaluation

Mechanisms have been established to evaluate the implementation process; nevertheless, the policy has been recently established and no accountable results have been obtained. The indicators are related to the:

  • Number of technologies identified
  • Number of technologies prioritised for assessment
  • Number of technologies assessed and with a positive answer for delisting
  • Economical consequences of delisting the technology
  • Health consequences of delisting the technology
  • Existence of an action plan to inform stakeholders (clinicians, patients, managers, policy makers, other providers, …)

The mid term review and final internal evaluations will be accomplished at least in the case of the Basque and Galician Autonomous Regions. Further developments have to be agreed at the Spanish level.

Review mechanisms

Mid-term review or evaluation, Final evaluation (internal)

Dimensions of evaluation

Structure, Process, Outcome

Results of evaluation

None at the moment.

Expected outcome

Some possible unintended side-effects could be: excessively bureaucratic mechanisms of control, no information provided to stakeholders or a way to delist technologies with doubtful value but producing a gap on health care provision. Other undesirable effects could be related to no accountable, transparent and systematic mechanisms, a lack of learning capacities in some organizations that provide health care or no mechanisms or incentives to those involved in the process.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low high very high

The impact of this policy could be high because it takes into account the opinions of different stakeholders, proposes a transparent process to delist health technologies and offers a more sustainable way of managing health technologies by considering not only the introduction of innvovation but the withdrawal of technologies of low added value that permits the re-allocation of resources and more active policies of innovation while maintaing the know-how of professionals.

References

Sources of Information

  • Ibargoyen-Roteta N, Gutiérrez-Ibarluzea I, Asua J. Report on the development of the GuNFT Guideline.i Guideline for Not Funding existing health Technologies in health care systems . Madrid: Plan de Calidad para el SNS del MSPS. Servicio de Evaluación de Tecnologías Sanitarias del País Vasco (Osteba); 2009. Informes de Evaluación de Tecnologías Sanitarias: OSTEBA Nº 2007/11.
  • Elshaug A, Hiller JE, Tunis SR, Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy 2007;4:23.  www.anzhealthpolicy.com/content/4/1/2
  • Ruano Raviña A, Velasco González M, Varela Lema L, Cerdá Mota T, Ibargoyen Roteta N, Gutiérrez Ibarluzea I, et al. Identification, prioritisation and assessment of obsolete health technologies. A methodological guideline. Quality Plan for the National Health System. Galician Health Technology Assessment Agency; 2007. HTA Reports: avalia-t No. 2007/01.

Author/s and/or contributors to this survey

Iaki Gutirrez Ibarluzea; Nora Ibargoyen Roteta; Gaizka Benguria Arrate; Lorea Galnares Cordero; Jos Asua Batarrita;

Osteba, Basque Office for Health Technology Assessment

Suggested citation for this online article

Gutiérrez-Ibarluzea, Iñaki; Ibargoyen-Roteta, Nora; Benguria-Arrate, Gaizka; Galnares-Cordero, Lorea; Asua-Batarrita José. "Withdrawal of technologies of low added value". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/es/a15/2