About SHARE
Background
Aims
Research questions
Methods
Model for evidence-based change
Data collection
Development of the framework
Results and Discussion
What concepts, definitions and perspectives underpin disinvestment?
Concept | Definition |
---|---|
Reallocation based on Relative value | “Disinvestment is an explicit process of taking resources from one service in order to use them for other purposes that are believed to be of better value” (Pearson and Littlejohns 2007 [1]) |
Reallocation based on Absolute value | “Disinvesting in health interventions that offer no or low health gain (eg are unproven, outdated or cost ineffective) provides an opportunity to invest in alternative proven and cost effective health interventions” (Victorian Department of Human Services 2007 [85]) |
Removal or restriction based on Absolute value | “Disinvestment relates to the withdrawing (partially or completely) of health care practices, procedures, technologies and pharmaceuticals that are deemed to deliver no or low health gain and are thus not efficient or appropriate health resources allocations” (Elshaug et al. [2]) |
Reasons for disinvestment | Considerations |
---|---|
Unsafe or harmful (Absolute) | ▪ Definitions or operational criteria not provided ▪ Emergency/major safety problems are already addressed through alerts and recalls, no definition or criteria for lower-level safety issues |
Less safe (Relative) | ▪ Higher rate of the same adverse events ▪ Other adverse events which are thought to be worse (but no guidance/criteria for comparison) |
Clinically ineffective (Absolute) | ▪ No or very low health gain ▪ No medical indication eg cosmetic procedure |
Less clinically effective (Relative) | ▪ Lower rate of the same positive outcomes ▪ Other positive outcomes thought to be less desirable (but no guidance/criteria for comparison) |
Cost ineffective (Absolute) | ▪ Considers effectiveness and cost ▪ Requires threshold, no definition or criteria provided |
Less cost-effective (Relative) | ▪ Provides less health gain for their cost than alternative ▪ No definition or criteria provided |
Outdated, superseded, obsolete | ▪ Inferior to more recently introduced TCPs ▪ No definition or criteria provided |
External factors | Political decisions, local priorities, rationalisation, organisational capacity and capability |
What models or methods of disinvestment have been implemented in hospitals or health services?
Topic | Issues |
---|---|
Organisational and management | ▪ How can a systematic evidence-based approach to disinvestment be implemented in a healthcare organisation? ▪ How can disinvestment decisions be integrated into established Strategic and Business Plans ▪ Which is the better approach – ‘top down’, ‘bottom up’ or both? ▪ How to engage and get ‘buy-in’ from clinicians, consumers and other stakeholders ▪ What are the relevant organisational change mechanisms? ▪ What does leadership for disinvestment involve? |
Decision-makers | ▪ Who has the authority, and the will, to make and act upon decisions about disinvestment? ▪ Who are the appropriate decision-makers? – Existing decision-making bodies or specially convened groups – Composition: policy-makers, managers, clinicians, consumers, technical experts, others – In-house or external ▪ How does the relevant information get to them? ▪ What other agendas do they bring to the decision-making table? ▪ Who has the time, relevant skills and adequate resources to identify, implement and evaluate the required practice changes? |
Decision-making | ▪ Are all viewpoints equal? ▪ What criteria should be applied to disinvestment decisions and prioritisation? ▪ What is the nature and source of information required? ▪ How do decision-makers become aware of the need to disinvest certain practices? ▪ How are policies and guidance documents used by local decision-makers to allocate resources? |
Assumptions | ▪ Are generally held assumptions true? For example – ‘Clinicians are reluctant to disinvest’ – ‘Disinvestment is not optimal unless an active intervention is in place’ |
Skills and resources | ▪ What expertise and training is required to make, communicate, implement and evaluate decisions? ▪ What resources are required to source expertise, source information, ‘backfill’ health service staff when participating, and support decision-making, implementation and evaluation processes? |
Professional and cultural | ▪ What impact will professional boundaries and ‘turf’ issues have on disinvestment activities? ▪ What are the rights and responsibilities of stakeholders? ▪ Different stakeholder views of what is meant by ‘little or no health benefit’ ▪ What is the effect of culture on disinvestment? (authoritative versus consultative, transparent versus hidden) ▪ What are the motives and incentives for disinvestment? |
Financial and commercial | ▪ What funding is required for disinvestment initiatives and where can it be found? ▪ How can the difficulties inherent in the complex funding arrangements within health services be overcome? ▪ How can savings be measured? ▪ How can savings be reinvested? |
Values and ethics | ▪ How can transparency of process be ensured? ▪ What is a ‘fair and reasonable’ process? ▪ What are the access, equity and legal considerations? ▪ What is the best way to deal with conflict of interest with commercial entities? |
Research and evaluation | ▪ What effect will the limited evidence base for some practices have on the process? ▪ How can the lack of tested methods for implementation and evaluation be addressed? |