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Disinvestment of ineffective, low value technologies is growing as a priority for international health policy in order to improve quality and maximize value in health care. Different strategies have been implemented at the international and national level using various methods of evidence gathering and technical assessment. However, the success of these initiatives is mixed, with fewer than half of the empirical studies reporting reductions in the use of low value services.
This review explored the role of stakeholders in the disinvestment process by describing the initiatives and analyzing the methods used for reassessment. We also identified the facilitators and barriers related to disinvestment implementation.
This scoping review was guided by the JBI Manual for Evidence Synthesis and the PRISMA statement for scoping reviews. Strategic literature searches were performed to identify published reviews on disinvestment in health care using the MEDLINE, Web of Science, and Scopus databases. Data were extracted using a predesigned form and then synthesized narratively to identify similarities and differences across the approaches according to prespecified domains.
Sixteen reviews were included. We identified various disinvestment initiatives across 16 countries, with a minimum of 34 initiatives at different levels of implementation and with various agencies responsible for the activities. Two of the most used methods for facilitating disinvestment decisions were program budgeting and marginal analysis (PBMA) and health technology assessment (HTA). Stakeholder involvement was the most important aspect to be addressed since it acts as both a facilitator and a barrier in implementing disinvestment initiatives. Meaningful engagement may be strengthened with continuous stakeholder participation, transparency in methods and processes, and ongoing knowledge transfer.
This scoping review highlights the role of stakeholder involvement in disinvestment, which is a double-edged sword because it both facilitates and hinders disinvestment implementation. The most common methods for assessing candidates for disinvestment are PBMA and HTA, but there is a lack of clarity on which HTA dimension is suitable for a disinvestment process.
Disinvestment from low value health technologies is growing globally. Diverse evidence gathering and assessment methods were used to implement disinvestment initiatives, however, less than half of the empirical studies report reduced use of the low-value services. This scoping review aimed to synthesize the information from available reviews on the concepts and purposes of disinvestment in healthcare, the approaches and methods used, the role of stakeholders and facilitators and barriers in its implementation.
This scoping review was guided by the Joanna Briggs Institute Manual for Evidence Synthesis and PRISMA statement for scoping review. Published reviews on disinvestment were identified from scientific databases including health technology assessment (HTA) Web sites using the terms “disinvestment,” “health technology reassessment,” and “healthcare.” The data obtained was synthesized narratively to identify similarities and differences across the approaches based on the prespecified categories.
Seventeen reviews were included with thirty-four initiatives identified across sixteen countries at various levels of implementation and responsible agencies for the activities. Two most used methods to facilitate disinvestment decisions are Programme Budgeting and Marginal Analysis (PBMA) and HTA. Stakeholder involvement is the most important aspect to be addressed, as it acts as both facilitator and barrier in disinvestment initiatives implementation.
Disinvestment programs have been implemented at multilevel, involving multistakeholders and using multiple methods such as PBMA and HTA. However, there is a lack of clarity on the additional dimensions of technical analysis related to these tools. Further research could focus on technology optimization in healthcare as part of overall health technology management.
Type 2 diabetes results mainly from weight gain in adult life and affects one in twelve people worldwide. In the Diabetes REmission Clinical Trial (DiRECT), the primary care-led Counterweight-Plus weight management program achieved remission of type 2 diabetes (for up to six years) for forty-six percent of patients after one year and thirty-six percent after two years. The objective of this study was to estimate the implementation costs of the program, as well as its two-year within-trial cost effectiveness and lifetime cost effectiveness.
Within-trial cost effectiveness included the Counterweight-Plus costs (including training, practitioner appointments, and low-energy diet), medications, and all routine healthcare contacts, combined with achieved remission rates. Lifetime cost per quality-adjusted life-year (QALY) was estimated according to projected durations of remissions, assuming continued relapse rates as seen in year two of DiRECT and the consequent life expectancy, quality of life and healthcare costs.
The two-year intervention cost was EUR 1,580 per participant, with over eighty percent of the costs incurred in year one. Compared with the control group, medication savings were EUR 259 (95% confidence interval [CI]: 166–352) for anti-diabetes drugs and EUR 29 (95% CI: 12–47) for anti-hypertensive medications. The intervention was modeled with a lifetime horizon to achieve a mean 0.06 (95% CI: 0.04–0.09) gain in QALYs for the DiRECT population and a mean total lifetime cost saving per participant of EUR 1,497 (95% CI: 755–2,331), with the intervention becoming cost-saving within six years.
The intensive weight loss and maintenance program reduced the cost of anti-diabetes drugs through improved metabolic control, achieved diabetes remission in over one-third of participants, and reduced total healthcare contacts and costs over two years. A substantial lifetime healthcare cost saving is anticipated from periods of diabetes remission and delaying complications. Healthcare resources could be shifted cost effectively to establish diabetes remission services, using the existing DiRECT intervention, even if remissions are only maintained for limited durations. However, more research investment is needed to further improve weight-loss maintenance and extend remissions.
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