Introduction: At present there is a growing interest in obsolete health technology identification and assessment. A number of institutions are initiating activities targeted in this direction because the classification of given technologies as obsolete would amount to an important benefit for patients and health systems, in that patients would stop being treated with less effective or less safe technologies. Despite this growing interest, a negligible amount of literature has been published on the topic, as this is a little developed field in health technology assessment, and so a great part of the content matter of this guide has been based on expert opinion. The working group defined obsolete health technology as any health technology in use for one or more indications, whose clinical benefit, safety or cost-effectiveness has been significantly superseded by other available alternatives.
Objectives: To propose a methodology for identification, prioritisation and obsolete health technology assessment.
Methods: We conducted a review of the scientific literature until April 2009 in specialised systematic review databases, such as HTA (Health Technology Assessment), DARE (Database of Abstracts of Reviews of Effectiveness), NHS EED (National Health Service Economic Evaluation Database) and the Cochrane Plus Library; and in general databases, such as Medline, Embase, IME (Índice Médico Español-Spanish Medical Index) and IBECS (Índice Bibliográfico en Ciencias de la Salud).
Furthermore, a number of databases and Internet search engines were reviewed, with special emphasis on the web pages of various national health technology assessment agencies and government bodies, particularly in the area of health services research. For perusal of the complete text, we selected records in which any type of obsolete technology was assessed or which contained opinions, ideas, advantages or limitations concerning any aspect linked to obsolete health technologies. There were no inclusion or exclusion criteria per se: instead, these records were selected on a consensus basis by two authors. In addition to the systematic review, a specific methodology was developed for each of the guide’s 3 sections.
Results: This methodological guide proposes three differentiated sections for identification, prioritisation and assessment of potentially obsolete health technologies. For the first of these sections (identification), five potential detection sources, classified as active or proactive, were established. Active sources include: 1) direct consultation of medical literature (in Medline-type databases); 2) consultation of new and emerging technology databases (EuroScan, GENTecS, Hayes, ECRI, ASERNIP-S); 3) consultation of systematic reviews published in the literature or by assessment agencies; and, 4) consultation with secretariats tasked with updating National Health System, hospital or regional service portfolios. Insofar as proactive systems are concerned, networks of health professionals would submit reports on potentially obsolete technologies to health technology assessment agencies or units. After probably obsolete health technologies had been detected by means of any of the above channels, the assessment agencies would then use a standardised procedure to confirm that the identified technology could be classified as potentially obsolete and be prioritised or, alternatively, assessed in cases where it had already been duly prioritised for the purpose.
To prioritise potentially obsolete health technologies for subsequent assessment, a prioritisation tool (PriTec tool) and a web application were created. This tool consists of three domains (population/end-users; risk/benefit; and costs, organisation and other implications) with a total of ten criteria. These domains have a weight on the scale of 36.7%, 36.7% and 26.6% respectively. Clinicians, managers and end-users participated in the weighting of the scale and selection of criteria. Using these results, a web application in Spanish and English, which is available and usable free of charge, can be accessed via the avalia-t web page (http://avalia-t.sergas.es/) or directly at www.pritectools.com or www.pritectools.es, and enables up to 50 potentially obsolete health technologies to be compared and prioritised for assessment purposes.
To assess a potentially obsolete technology, an assessment-document structure has been proposed, with different sections, centred on comparison of the benefits (in terms of efficacy and of safety, efficiency, cost or other implications) of the potentially obsolete versus the proposed alternative technology. The technology assessment section is based on a systematic review and should meet the requirements of being straightforward, methodical and reproducible.
Discussion: The guide can be used by different bodies interested in obsolete health technology assessment. All sections of the guide have advantages and limitations. The identification section should be used on a pilot basis to ascertain which sources of detection are most appropriate or efficient for identification of potentially obsolete health technologies. The prioritisation section enables a range of potentially obsolete technologies to be compared. This is an initial version which can be improved over the course of time. It will be interesting to see how it performs and the degree to which it is used in settings other than Spain.
Conclusions and recommendations: To assess any obsolete health technology, a standardised process that enables identification, prioritisation and assessment of such technologies must be established. It is essential to determine the impact to be expected a priori from defining any given technology as obsolete, since the greater the impact, the more the health system will benefit from its assessment and subsequent exclusion.