Managing obsolete technologies and disinvestment in the Basque

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                         2008 July the 6th

     Managing obsolete technologies and disinvestment
          in the Basque Country’s Health System
                              Osteba. Osasun Teknologien Ebaluazioaren Zerbitzua.
                                            Basque Office for HTA.
                                        Osasun Saila Ministry of Health
                                     Eusko Jaurlaritza Basque Government


Basque Autonomous Region

2.124.000 inhabitants (2005)

Health transference 1979

Health system with full coverage

Main purchaser (Ministry of Health of the Basque Country)

Basque Health Service (Osakidetza) created on 1983
     HTA objetives

To help in decision making about the incorporation of new
and emerging health technologies
To reduce the risk of introducing no effective or harmful
To share the obtained information and to contribute with
relevant data about the technology
To give advice about externally identified technologies
Collaboration in the establishment of scenarios
Identification/establishment of criteria to disinvest
(reinvestment) obsolete technologies (reallocation of
      Health Tecnology Assessment:
      The Basque Country

Basque Office for HTA, Osteba, created in 1992.
SorTek, early warning system established in 2000.
Founder members of EuroScan, GIN, AUnETS
Members of INAHTA, HEN, HTAi and EUNetHTA (associated
In 2004: Regulatory law (not drugs) for the introduction of new
and emerging health technologies

     BUT what happens with obsolete technologies?
¿Obsolete technologies?
     Obsolete definition? (I)

      Non admissible safety          Non effective


    Non cost-effective                  Redundant

                   Used in no appropriate

* In comparison to other technologies??
       Obsolete definition? (II)

Obsolete/outmoded/superseded: a technology that has been
superseded by other technologies or demonstrated to be
ineffective or harmful

Spanish Group:
Obsolete technology/indication: Health Technology or its
application in a concrete indication whose clinical benefit,
security or cost-effectiveness has been superseded in a
significant way by other available alternatives

Disinvestment relates to the processes of withdrawing
(partially or completely) health resources from any existing
health care practices, procedures, technologies and
pharmaceuticals that are deemed to deliver no or low health
gain for their cost and are thus not efficient health resource
Adam Elshaug, 2007
    Some difficulties to take into account

In relation to Obsolete technologies:
   Less interest on efficacy and effectiveness data collection
   after the adoption of a technology

In relation to Disinvestment:
   More difficult to delist when ineffectiveness/ inefficacy
   Alternative technologies and target population
   Disinvestment of obsolete technologies depends on
   obsolete definition
   Implementation problems of disinvestment methodologies
    Obsolete strategy in Spain

Collaboration Project (AVALIA-T and Osteba) to identify,
prioritize and assess obsolete technologies
  Knowledge of the situation in other context:
     Contact with other organizations (INAHTA- EuroScan)
     Bibliography searches

  Definition of obsolete technologies and variables of interest
  Prioritization criteria for assessment
  Case-Study testing
  FINAL AIM: Methodological Guide
         Obsolete strategy in the Basque Country

1. Identification process
       Experts net (ZaharTek= SorTek + …)
          Obsolete technologies identification by PILOT questionnaire
          Verification of technology obsolescence
       Literature review
       Euroscan database
2. Selection of variables for prioritization and evaluation:
      In collaboration with AVALIA-t
3. Case Study to test the evaluation tool
4. GuNFT Guide elaboration
       Hospital Guide not to invest on existing technologies with no proven
    effectiveness for a concrete indication or indications
      1. Identification (1):
         Results of the PILOT questionnaire

Cobalt bomb VS linear multi-energy accelerators
2D LinAcs planning VS 3D LinAcs planning or IMRT
Initial Chemotherapy due to waiting lists in radiotherapy
treatment VS Simultaneous Chemotherapy and Radiotherapy
Non multilaminar accelerators VS Multilaminar accelerators
Patients location only with laser VS Image guided Radiotherapy
Radium VS Iridium 198
Cartography (ineffective) VS EEG-video or functional MRI
Motor rehabilitation techniques using optometric methods
        1. Identification (2):
        Results of the PILOT questionnaire

Second round answers to the questionnaire:
1. ICU:
       Antiarrithmics in AMI vs Revascularization
       Anti-TNF in Sepsis
       Gammagraphy in Pulmonary Thromboembolism vs TAC
       Arteriographies in bleeding vs TAC and MRI
       High frequency ventilation

2. Gynecology, hematology, internal medicine y
   urology didn’t know any obsolete technologies
      1. Identification (3):
         Things to learn from our experience

Effectiveness and safety aspects
Answers from more technified units
   Radiotherapy Oncology
   Neurology (imaging)
   Psychiatry and gynecology, hematology, internal medicine and
   urology : they don’t know any
More collaborative experts:
   Those who knows the clinical reality
   Technological frustration
   When disinvestment would mean future investment or reinvestment
     Identification. Literature search

Not many experiences in the world
  Australia-New Zealand
  Project in Israel
  Some experiences in the USA
Most of the experiences related to disinvestment
Used techniques:
  Marginal analysis
  Surveys on preferences
              Identification. EuroScan database

                                                                                       1,129 technologies in EuroScan
                                                                                       274 technologies (24.3% substitutives)






      D e v ic e   D e v ic e / P ro c e dure   D ia gno s t ic s    D rug     D rug/ pro c e dure   O t he r   P ro c e dure   P ro g ra m

                                                                    T ype of technology
      2. Variables for evaluation (and

General information about the Technology of Interest
The context of the technology
Why is the technology considered obsolete?
Information about costs, effectiveness and security of the
Possibility of being eliminated or substituted by an alternative
Information about costs, effectiveness, security of the alternative
Possible consequences to take into account
     3. Case Study to test the evaluation tool

Selection of 4-5 technologies:
   Diagnostic procedure
       Rx in craneum encephalic trauma
   Therapeutic technology
      Cobalt bombs
   Preventive technology
            4. GuNFT Guide elaboration

 Identification of criteria for disinvestment
                                                •   Management
                                                •   Medical Direction
                                                •   Clinicians
Nominal Group Methodology
                                                •   HTA
                                                •   Financing and Contract
                                                •   Health Plan
                                                •   Ethic and Juridical
          GuNFT Guide                           •   Patients
          (for Hospitals)                       •   General Director
     4. GuNFT Guide elaboration
     Nominal group technique (i)

Meeting in Bilbao with experts and opinion leaders
  Presentation of the project
  8 questions about the different aspects of technology disinvestment
  in hospitals
  3 rounds
  10 specialist of different areas (key informants)
     HTA, quality management, patients, ethics-law, nuclear medicine, management,
     Health care service decision maker and economist.
       4. GuNFT Guide elaboration
       Nominal group technique (ii)

Results (139 criteria)
   Technology: 18 criteria
   Hospital characteristics: 18 criteria
   Organizational: 20 criteria
   Patient characteristics: 17 criteria
   Information needs: 15 criteria
   Professional barriers: 17 criteria
   Decision admittance: 18 criteria
   Ethical, social, juridical, political: 17 criteria

   Scoring: choose 10 criteria (1-10). Concordance analysis and
   determination of a cut-off point
     Managing health technologies in the
     Basque Country

                                   General                  Specific
                     Web alerts                                        Journals
                                  Databases                Databases

          Industry                 Agency 2                Agency 3    Agency 4              Experts






 Monitoring                                     Files
      Obsolete technologies. Conclusions

Reinforce positive points in the disinvestment-delisting
   New possibilities for reinvestment
   More efficient Health Care Systems
   Do the right thing at the right moment in the right place
   Open mind for innovation
   Professionals found the process itself positive
   Context dependent
   Sometimes it can’t be say obsolete technology but obsolete