Finding the needle in the haystack: identifying low-value medical

interventions from the medical literature

Health Technology Assessment international (HTAi) Annual Meeting26 June 2012: 14.00-15.30

(Abstract ID: 448)

Presenting author: Dr Sarah Garner

Authors: Tom Hudson, Tarang Sharma, Moni Choudhury (NICE)

Disinvestment

• The term disinvestment in health care is gaining prominence internationally. It relates to:

“the processes of (partially or completely) withdrawing health resources from any existing health care practices, procedures, technologies or pharmaceuticals that are deemed to deliver little or no health gain for their cost, and thus are not efficient health resource allocations.”1

(Elshaug, Moss, Littlejohns et al, 2009).

Background

• Identification of low-value healthcare interventions with the intention of withdrawing them (‘disinvestment’) is a topic of interest in all health systems.

• Little research has explored methods for identifying low-value interventions.

• One potential approach is to use the medical literature.

NICE products

• NICE currently provides the following collections of repackaged recommendations in order to inform evidence-based disinvestment decisions:– NICE ‘do not do’ recommendations– Quality and Productivity Cochrane topics– NICE referral advice recommendations

Objective

• To explore the feasibility of using a general search of the main biomedical literature databases to identify:

– health-care interventions or services as potential candidates for disinvestment

– methodological or policy papers on the subject of disinvestment.

Methods

• Pragmatic search strategies were developed, informed by contact with other HTA agencies.

• Build on the work by Galician Health Technology Assessment Agency (Avalia-T).

• These were applied to Medline, Medline in-Process; Embase and the Cochrane Methods Register.

• Titles and abstracts were filtered for relevance.• Relevant papers were coded as:

– potential disinvestment candidate topics– methodological articles– policy papers.

Eligibility criteria

• Inclusion Criteria: – All articles where candidate topics for disinvestment are

identified systematically through a systematic review and guidelines for practice.

– All articles discussing methodological issues or suggesting methods for disinvestment.

– All policy articles discussing the political context around disinvestment.

• Exclusion Criteria:– All topics for disinvestment suggested through unsystematic

literature reviews, trials, case series or registry data.– All articles discussing methods for cost-effectiveness analyses

or systematic reviewing in general.

Search strategy

Database: Ovid MEDLINE(R) <1948 to January Week 2 2011>

1 disinvest*.tw.2 obsole*.tw.3 "sub optimal".tw.4 outmoded.tw.5 outdated.tw.6 "out moded".tw.7 "out dated".tw.8 "out of date".tw.9 "low value".tw.10 (little adj2 value).tw.11 (marginal* adj2 (value or (cost adj effective*) or analys*)).tw.12 (decremental* adj cost adj effectiv*).tw.13 (substitut* adj technolog*).tw.14 delist*.tw.15 (de adj list*).tw.16 decommission*.tw.17 supersede*.tw.18 supercede*.tw.19 (treatment* or technolog* or service* or practice* or activit* or device* or test* or intervention* or therap*).tw.20 exp "costs and cost analysis"/

exp "costs and cost analysis"/21 exp Health Planning/22 exp "Costs and Cost Analysis"/23 exp Resource Allocation/24 exp Decision Making/25 exp Decision Support Techniques/26 exp Technology Assessment, Biomedical/27 cost*.tw.28 (cba or cea or cua).tw.29 (expens* or expenditure).tw.30 value.tw.31 pric*.tw.32 (pharmacoeconomic* or (pharmaco adj economic*)).tw.33 ration*.tw.34 budget*.tw.35 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 1836 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 3437 (ineffect*.tw adj5 19) and 3638 19 adj5 3539 1 or 37 or 3840 limit 39 to yr="2001 -Current"

Results (1)

Results (2)

Results (3)

Conclusions

• Searching for disinvestment-related articles is a challenge due to the lack of a widely-adopted, shared vocabulary and the absence of specific index terms.

• It provides a low-yield of potential topics.• In addition many such interventions have been

inadequately researched, and many trials with negative results remain unpublished (publication bias).

• Given how resource intensive this approach is, efforts may be better focussed on alternative identification strategies, for example engagement with clinicians.

References

1. Elshaug AG, Moss JR, Littlejohns P, Karnon J, Merlin TL, Hiller JE (2009) Identifying existing health care services that do not provide value for money. Med J Aust;190:269-73.

Links/Contact detailsLinks:Research and Development, NICE:http://www.nice.org.uk/aboutnice/howwework/researchanddevelopment/about.jsp

Authors: • Dr Sarah Garner, Associate Director• Mr Thomas Hudson, Information Specialist• Ms Tarang Sharma, Senior Analyst• Miss Moni Choudhury, Analyst

Contact:• Sarah Garner, Tel: 44 (0)20 7045 2097; • Email: Sarah.Garner@nice.org.uk