At a European level, the EUnetHTA’s (European Network for Health Technology Assessment) recent proposal to the European Commission for a stable structure of health technology assessment in Europe acknowledges the importance of obsolete health technologies, indicating under the “Vision” section that, “new health technologies can be adopted and obsolete technologies abandoned in a well-informed and robust manner, hence bringing about high quality, safe, accessible, sustainable, ethical and efficient health care for citizens across Europe.” Within the added value of inter-agency collaboration, it lays stress on, “sharing a variety of information on health technologies (from emerging to established and disinvested technologies)” (8).
Different institutions, such as the National Institute for Health and Clinical Excellence (NICE), Australian Government, Swedish Council on Technology Assessment in Health Care (Statens beredning för medicinsk utvärdering - SBU) and NHS Scotland, have recently acknowledged the importance of obsolete and ineffective health technologies. A 2008 European Observatory on Health Policies and Systems document entitled, “Ensuring value for money in Health Care. The role of health technology assessment in the European Union” (9) indicates that there is a very limited HTA information for identifying areas of disinvestment and that more attention should be paid to identifying them, so that such ineffective and obsolete technologies do not remain in the health systems any longer.
In England, the NICE has shown interest in initiating a programme on ineffective treatments and, to this end, has entered into an agreement with the National Health Service (NHS) whereby the NICE will provide guidance, in this respect, on disinvestment from and identification of interventions in use which are not appropriate, effective or financially profitable (10). This initiative arose after the need had been voiced from different quarters for the NICE and the NHS to begin working on disinvestment (11), and also after the NHS had recommended that the NICE work with greater intensity on disinvestment and adopt an approach to cost-effectiveness similar to that used when it evaluates new technologies to cover ineffective technologies. On 6 September 2006, the NHS formally called on the NICE to launch a programme that would help it reduce expenditure on treatments that failed to improve patient care (12). As explained, rather than focus on aspects of cost-ineffectiveness, the aim of this guide is to highlight the lower effectiveness and safety of obsolete technologies, though we do recognise that disinvestment is a very important point in the assessment of such types of technologies.
The NICE has proposed three ineffective technologies to be analysed in greater depth (topical use of antibiotics for suspected acute bacterial conjunctivitis, tetracyclines for acne vulgaris, and topical use of combinations of antimicrobials and corticoids in superficial inflammatory dermatoses) (13). Within this ineffective technology analysis programme, the NICE will develop three types of products: assessment of technologies and clinical guidelines targeted at reducing ineffective practices; recommendation reminders (on ineffective technologies in existing NICE guidelines); and commissioned guidelines.
In a document on revising and extending its remit, the Scottish Health Technologies Group also recommends that health technology disinvestment activities be initiated (14). In the case of disinvestment, it indicates that, before embarking upon appraisal, “Topics for disinvestment might need an initial summary analysis of the degree of evidence available, and potential scale of cost saving, to determine whether an assessment/appraisal was justified”.
Australia is one of the countries which, to date, has shown the keenest interest in obsolete technologies and disinvestment. Thus, the Regional Government of Victoria sponsored a workshop to ascertain the response which disinvestment from health technologies might elicit. This same workshop also laid down certain guiding principles under which disinvestment from technologies should move forward (15).
At the University of Adelaide, Elshaug et al (16-17), en la Universidad de Adelaida, han realizado propuestas en relación con la desinversión en tecnologías. En uno de sus artículos (17) have made proposals regarding disinvestment from technologies. One of their papers (17) outlines the changes that must be made in political processes in order to meet the challenge of disinvestment from ineffective health technologies. The five key points to be resolved would be: 1) lack of resources to support disinvestment policy mechanisms; 2) lack of reliable administrative mechanisms to identify and prioritise technologies and/or practices with uncertain clinical and cost-effectiveness; 3) political, clinical and social challenges to removing an established technology or practice; 4) lack of published studies with evidence demonstrating that existing technologies/practices provide little or no benefit; and, 5) inadequate resources to support a research agenda to advance disinvestment methods. Subsequently, a qualitative study performed on 10 Australian health managers was published in 2008 containing their opinions on disinvestment from ineffective health practices. In this study, three priority topics are identified: a) lack of attention to existing practices is due to limitations in resources and methodological complexity; b) advance in disinvestment calls for expressly focusing on the saving of potential costs to be achieved through improvements in health care quality; and, c) financial support and collaboration are needed for advancing research into the methodological underpinnings associated with health technology assessment, and specifically with disinvestment from such technology.
Finally, in Canada, expressly listed among the functions of the Ontario Health Technology Advisory Committee is the withdrawal of obsolete health technologies (18, 19), though there is no indication as to the methodology used or even if this exists.