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Case studies that illustrate disinvestment and resource allocation decision-

making processes in health care: A systematic review

Article  in  International Journal of Technology Assessment in Health Care · March 2013

DOI: 10.1017/S0266462313000068 · Source: PubMed

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International Journal of Technology Assessment in Health Care, 29:2 (2013), Page 1 of 11.
c Cambridge University Press 2013


doi:10.1017/S0266462313000068
Theme Submission
Case studies that illustrate
disinvestment and resource
allocation decision-making processes
in health care: A systematic review
Julie Polisena, Tammy Clifford Craig Mitton
Canadian Agency for Drugs and Technologies in Health Department of Epidemiology and Community School of Population & Public Health, University of British Columbia Centre for Clinical
Medicine, Faculty of Medicine, University of Ottawa Epidemiology and Evaluation, Vancouver Coastal Health Research Institute
Adam G. Elshaug Erin Russell
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts School of Canadian Agency for Drugs and Technologies in Health
Population Health, The University of Adelaide Becky Skidmore
Independent Researcher and Information Specialist

Objective: Technological change accounts for approximately 25 percent of health expenditure growth. To date, limited research has been published on case studies of disinvestment
and resource allocation decision making in clinical practice. Our research objective is to systematically review and catalogue the application of frameworks and tools for disinvestment
and resource allocation decision making in health care.
Methods: An electronic literature search was executed for studies on disinvestment, obsolete and ineffective technologies, and priority healthcare setting, published from
January 1990 until January 2012. Databases searched were MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, Embase, The Cochrane Library, PubMed, and
HEED.
Results: Fourteen case studies on the application of frameworks and tools for disinvestment and resource allocation decisions were included. Most studies described the application of
program budgeting and marginal analysis (PBMA), and two reports used health technology assessment (HTA) methods for coverage decisions in a national fee-for-service structure.
Numerous healthcare technologies and services were covered across the studies. We describe the multiple criteria considered for decision making, and the strengths and limitations of
these frameworks and tools are highlighted.
Conclusions: Disinvestment and resource allocation decisions require evidence to ensure their transparency and objectivity. PBMA was used to assess resource allocation of health
services and technologies in a fixed budget jurisdiction, while HTA reviews focused on specific technologies, principally in fee-for-service structures. Future research can review the
data requirements and explore opportunities to increase the quantity of available evidence for disinvestment and resource allocation decisions.

Keywords: Disinvestment, priority setting, resource allocation health policy

In 2010, the healthcare spending was estimated to reach home care, new technologies, and health human resources, the
CAD192 billion (USD185 billion) in Canada, representing 11.7 Conference Board of Canada labeled technological change as a
percent of the country’s gross domestic product (1). Although cost escalator because it accounts for approximately 25 percent
a large portion of expenditures is related to pharmaceuticals, of health expenditure growth (2).
Disinvestment is defined commonly as the complete or par-
tial withdrawal of resources from healthcare services and tech-
nologies that are regarded as unsafe, ineffective or inefficient,
This work has been completed in partial fulfillment of the requirements for Julie Polisena’s PhD with those resources shifted to health services and technologies
degree in Epidemiology at the University of Ottawa. Julie Polisena is funded by the University of with greater clinical- or cost-effectiveness (3). For this review,
Ottawa Admission Scholarship. Adam Elshaug is funded by a National Health and Medical we defined healthcare technologies as drug therapies, medical
Research Council (NHMRC) of Australia, Sidney Sax Fellowship (ID 627061). Craig Mitton is
devices, diagnostic and screening tests, vaccines, and surgical
funded by the Michael Smith Foundation for Health Research. The authors thank Hayley
Fitzsimmons for her information service support.
and non-surgical procedures.
Drs. Mitton and Elshaug have focused their research in this broad (and often specific) area of Multiple barriers exist that render the development of disin-
enquiry and acknowledge, therefore, an intellectual interest. Their contribution to this study was vestment methods a challenge. Elshaug et al. highlighted several
intended to embody expert guidance with minimal bias. Despite this, both acknowledge the obstacles related to a dearth of published evidence and policy
potential for conflict in this regard. mechanisms to support the advancement of disinvestment, as

1
Polisena et al.

well as political, clinical and social challenges. Moreover, there of framework or tools based on individuals who participated
is a lack of incentives for clinicians to disinvest from ineffective in the process. Reports that did not present a list or categories
technologies, and the removal of technologies and procedures of candidate health services or technologies for disinvestment
may cause concern for health professionals and patients who or the criteria considered during the decision-making process
will view the exercise as a reduction of available health services or were published in a language not spoken by any of the co-
(3). To date, limited research has been published on case stud- authors were excluded from our review. Two reviewers (J.P.
ies of frameworks and tools used for disinvestment and resource and E.R.) selected the final articles for inclusion based on
allocation decision making in health care. examination of the full-text publications. Any disagreements
between the reviewers were discussed until a consensus was
OBJECTIVES reached.
Our research objective was to systematically identify case stud-
Data Extraction
ies in the published and gray literature that describe disinvest-
One reviewer (J.P.) conducted the data abstraction for all se-
ment and resource allocation processes for real-world decisions
lected studies using a pre-specified extraction form that included
in health care. This analysis helps to identify the gaps that exist
the study characteristics and the suggested criteria to inform
with current methods used for disinvestment and resource allo-
the prioritization of disinvestment opportunities published by
cation and will inform directions for future research on priority
Elshaug et al. (4). Another reviewer (E.R.) verified the accuracy
healthcare setting.
of the data extracted. Any disagreements were discussed until a
consensus was reached.
METHODS
Quality Assessment
Literature Search Strategy Because the selected articles are descriptive, a formal quality
Published literature was identified by searching the following assessment using validated critical appraisal instruments was
bibliographic databases: MEDLINE with in-process records not conducted. Also, the intent of our systematic review was to
and daily updates via Ovid; Embase via Ovid; The Cochrane present examples of the disinvestment decision-making process
Library (2011, Issue 2) via Wiley; PubMed; and the Health across various healthcare contexts rather than to test a hypoth-
Economic Evaluations Database (HEED). The main search con- esis.
cepts include disinvestment, obsolete and ineffective technolo-
gies, and priority healthcare setting. Retrieval was limited to Data Analysis and Synthesis
documents published between January 1990 and January 2012. Published studies that illustrated the use of frameworks and tools
The search timeframe extended to 1990 because disinvestment for disinvestment processes were described narratively. Also
activities occurred in the 1990s within Canadian provincial their strengths and limitations, based on stakeholder feedback,
health insurance plans (3). It should be noted that these reports were discussed. All dollar amounts were converted to 2012 U.S.
did not present any specifics about the frameworks used, imple- dollars.
mentation strategies, and, although candidates were nominated,
outcomes were not provided of health services and technologies RESULTS
that were actually delisted. In addition, disinvestment activities
occurred in the 1970s with the Blue Cross Blue Shields Medical Quantity of Research Available
necessity program in the United States but has been excluded The electronic literature search and alerts yielded 2,963 cita-
here to retrieve more recent studies on disinvestment (3). No tions. Upon screening titles and abstracts, 123 potentially rel-
language restrictions were applied, and gray literature (litera- evant articles were retrieved for full-text review. An additional
ture that is not commercially published) was identified. Details seven potentially relevant reports were identified through the
are reported in Supplementary Table 1, which can be viewed gray literature. Of the 130 potentially relevant reports, 116 re-
online at www.journals.cambridge.org/thc2013090. ports did not meet the selection criteria. The study selection pro-
cess is presented in a Preferred Reporting Items for Systematic
Selection Criteria Reviews and Meta-Analyses (PRISMA) flowchart (Figure 1).
The selection criteria included articles that provided a case
scenario for the application of a framework or tool that sup- Study Characteristics
port decisions on disinvestment in a real-world health context. Four studies were conducted in Australia (5–8), four in Canada
Eligible articles included those that presented information on (9–12), another four in the United Kingdom (UK) (13–
the framework or tool used; health technologies and service 16), one each in New Zealand (17) and Sweden (18). The
assessed; the criteria considered for disinvestment decisions, publication years ranged from 1995 (13) to 2011 (6;7;9).
including resource allocation; and the rationale behind and im- Table 1 highlights the key findings in the selected case
pact of disinvestment decisions; and strengths and limitations studies, and a summary of characteristics, criteria used for

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013 2

 Case studies on disinvestment and reallocation

2,963 citations identified from

electronic literature search and
screened

2,840 citations
excluded

123 potentially relevant articles

retrieved for scrutiny (full text, if
available)

7 potentially relevant
reports retrieved from
other sources (gray
literature, hand search)

130 potentially relevant

reports

116 reports excluded:

• irrelevant framework or tool (28)

• irrelevant to health technologies
or healthcare context (18)
• irrelevant to disinvestment (18)
• did not present an application of
framework of tool (23)
• published in language other than
English (2)
• other (review articles, surveys,
editorials) (27)

14 case studies included in

review

Figure 1. Selection of included studies.

decision making and potential impact of decisions are pre- nology (19). One study from Sweden applied the Accountability
sented in Supplementary Table 2, which can be viewed online for Reasonableness (A4R) Model and quality improvement the-
at www.journals.cambridge.org/thc2013090. ory and technologies, which addressed concepts on rationing,
rationalization, ranking priority setting, and structured quality
Healthcare System Level. In three reports, proposals related to dis-
improvement (18). Two studies also described the specific appli-
investment opportunities occurred at the national level (6–8), cation of the accountability for reasonableness framework, an
seven studies assessed resource allocation at the health author- approach based on justice theories and ethics for a fair priority
ity or regional level (9;12;13;15–18), and four studies reviewed setting process (12;18).
services and technologies provided in institutions (5;10;11;14).
Framework and Tool Used. Eleven studies used program budget and Healthcare Technologies and Services Assessed for Disinvestment. An array of
marginal analysis (PBMA) to make decision related to the in- healthcare technologies and services were covered across the
vestment and disinvestment of healthcare technologies or ser- studies. Health services and programs related to non-acute ser-
vices (5;8–17). Two studies used the health technology assess- vices, home and community, mental health, gynecology, mater-
ment (HTA) approach for their disinvestment recommendations nity, and child health services were discussed in several studies
(6;7). Health technology assessment is defined by the Interna- (9;12). One hospital examined the provision of surgical services,
tional Network of Agencies for Health Technology Assessment and another hospital wanted to shift resources from inpatient to
as a multidisciplinary field of policy analysis. It involves a sys- outpatient surgeries (10;11). Health technologies and services
tematic evaluation of the medical, social, ethical, and economic for chronic airflow limitation were proposed for disinvestment
implications of development, diffusion, and use of health tech- in a teaching hospital in Australia (5). The prioritization of

3 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013

Polisena et al.
Table 1. Case Studies on Disinvestment Decision Making

Healthcare technologies
First author, year, and country and services proposed for Disinvestment and resource allocation recommendation
of publication Framework or tool used disinvestment Potential cost savings with proposed disinvestment and/or decision

MSAC(6), 2011 Australia HTA Vertebroplasty and Vertebroplasty: AUD2.191M (USD 2.244M) to AUD Discontinue public funding of kyphoplasty and
kyphoplasty 3.745M (USD 3.836M) percutaneous vertebroplasty for vertebral compression
Potential cost savings to MBS: AUD0.694M (USD
0.711M) to AUD1.187M (USD1.216M)
Potential cost savings to State or Territory Governments
with removal of vertebroplasty: AUD0.201M (0.206M)
to AUD0.344 (USD 0.352M)
Not available for kyphoplasty
MSAC(7), 2011 HTA Lumbar AIDR Lumbar fusion: AUD6.66M (USD6.822M) Continue ongoing public funding of lumbar AIDR
Australia Lumbar AIDR: AUD6.23M (USD6.382M)
Potential cost savings with using lumbar AIDR: AUD0.43M
(USD0.44M)
Mitton(9), 2011 PBMA Non-acute services CAD4,912,167 (USD5,017,425) All disinvestment recommendations and limited number of
Canada (specific programs were investment initiatives were approved by senior
4

not listed) executives but were subject to Board approval in 2010

Ball(14), 2009 PBMA Mental health GBP3.77M in 2008/2009 (USD5.86M) • GBP194,000 (USD 301,550) reduction from changes
United Kingdom in prescription practices
• Released funds would help to fund a holistic mental
well-being service and the development of young
persons’ one-stop shop
Urquhart(12), 2008 PBMA and A4R Home and community CAD153,159 (USD165,093M) Three disinvestment proposals (not specified) were
Canada care programs recommended by advisory panel and approved by senior
executive
Lindström(18), 2008 Quality improvement theory Infertility Reallocation from diagnostics to treatment: ∼0.5MSEK • Reduction in traditional diagnostic resource use expected
Sweden and technologies tools and (USD74,9000) by half
A4R • Tests were limited to medical examination of women,
sperm tests, blood tests, and tubal examination by
ultrasound with media
• Reduction in physical examinations to approximately
15% of men and 50% of women
• Reduction of tubal examinations to 10 of women
• Maximum treatment level was set at one full-scale
treatment and one frozen embryo
 Table 1. Continued

Healthcare technologies
First author, year, and country and services proposed for Disinvestment and resource allocation recommendation
of publication Framework or tool used disinvestment Potential cost savings with proposed disinvestment and/or decision

Mitton(10), 2003 PBMA Surgical services CAD23,110 in 2001/2002 (USD18,484) • Cheaper sterilization
Canada • Reduction in maintenance
• Reduction in overtime and callbacks
• Decision was interim
Spenceley(11), 2002 PBMA Ambulatory surgical Not available • Shift outpatient surgeries to 40–50% of laparoscopic
Canada services cholecystectomy patients, 45–55% of inguinal hernia repair
patients, 65–75% of reduction mammoplasty patients, and
45–55% of patients undergoing rotator cuff repair
Bohmer(17), 2001 PBMA Respiratory illnesses Not available • New resources were found for implementation, so
5

New Zealand disinvestment was not necessary

Carter(8), 2000 PBMA Cervical cancer screening Between AUD23,700,00 (USD20,723,796) and • Increase screening interval from two to three years
Australia program AUD50,600,000 (USD44,245,743) in cost savings • Increase age for screening of women to later than 18 years
Crockett(5), 1999 PBMA Chronic flow limitation Not available • Decrease in avoidable admissions and readmissions
Australia • Decrease in unnecessary days of inpatient stay
Ratcliffe(15), 1996 PBMA Maternity services • GBP598,320 (USD1,337,191) • Reduce antenatal visits: estimated savings based on staff
United Kingdom costs from fewer clinics
• Downsize activity at AMH:
• Move 960–1,090 maternities out of hospital
• Reduce postnatal length of stay for normal births from 3.5
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013

to 2.5 days;
• Downsize activity at Raigmore Hospital:

Case studies on disinvestment and reallocation

• Funds to be released from obstetrics, special care baby unit
and out-patients
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013

Polisena et al.
Table 1. Continued

Healthcare technologies
First author, year, and country and services proposed for Disinvestment and resource allocation recommendation
of publication Framework or tool used disinvestment Potential cost savings with proposed disinvestment and/or decision

Ruta(16), 1996 PBMA Child health services • Not available, but total expenditure for child health • School health service: Replace routine school medicals with
Scotland strategy program was GBP29,600,00 in selective examinations
1992/1993 (USD71,918,969) • Hospital admission (e.g., increase day surgery with 5 most
common surgical procedures)
• Health visitor service (e.g., alter skill-mix)
Twaddle(13), 1995 PBMA Gynecology • If 70% of women were managed as day cases for • Reduction in in-patient procedures
Scotland pregnancy terminations: GBP168,000 • Reduction in use of D&Cs
(USD399,239) savings (14% of current spending)
6

• If 60% of laparoscopies and laparoscopic sterilizations

were managed as day cases: GBP108,646
(USD258,189) savings (18% of current spending)
• If 75% of laparoscopies and laparoscopic sterilizations
were managed as day cases: GBP160,056
(USD380,361) savings (26% of current spending)
• Replacement of dilations and curettages (D&Cs):
GBP253,769 (USD603,062) savings (42% of
current spending)

A4R, Accountability for reasonableness; AIDR, Artificial intervertebral disc replacement; AUD, Australian dollar; CAD, Canadian dollar; GBP, British pound; HTA, Health technology assessment; M, million; MBS,
medical benefits schedule; MSAC, Medical services advisory committee; PBMA, Program budgeting and marginal analysis; USD, US dollar.
 Case studies on disinvestment and reallocation

reproductive technologies were assessed by the Swedish Par- Cost-Effectiveness and Opportunity Cost
liament (18). Two health regions in New Zealand reviewed the The cost-effectiveness of infertility treatments (18), vertebro-
allocation of health services and technologies for respiratory plasty versus conservative management (6), AIDR versus other
illnesses (13;17). In 2011, the Medical Services Advisory Com- lumbar procedures (7), and cervical cancer screening strategies
mittee (MSAC) reviewed artificial intervertebral disc replace- (8) were measured in four reports. Ruta et al. conducted a lit-
ment (AIDR) lumbar and vertebroplasty, along with kypho- erature search on the cost-effectiveness of otitis media, respite
plasty, for a coverage recommendations (6;7). Finally, cervical care, and school nurse and health visiting, and identified one
cancer screening to inform the National Cancer Strategy was economic evaluation on health visiting (16). Two case studies
reviewed in Australia (20). incorporated the optimal use of resources required for maxi-
Potential Cost Savings with Disinvestment Opportunities. Four studies did not mum benefit in patients receiving home and/or community ser-
report the reduced dollar amounts associated with the proposed vices (9;12). Other studies reviewed the costs associated with
disinvestment opportunities in healthcare technologies and ser- the technologies, services, and care program that would be im-
vices (5;11;16;17). The potential savings with the reduction pacted by the decision (10;11;13;15–17), and cost-effectiveness
or removal of health technologies or services ranged from ap- of interventions and opportunity costs of resource reallocation
proximately CAD23,110 in 2003 (USD18,484 in 2012) (10) to were not mentioned in two studies (5;14). It should be noted
AUD50,600,000 in 2000 (USD44,245,743 in 2012) (8). that, in cases where the technology is deemed to be clinically
ineffective and/or unsafe compared with the comparator, an eco-
Criteria Considered in the Case Studies. A brief description of the criteria
nomic evaluation will unlikely be conducted, although costing
considered in each case study is outlined below, with specific
analyses may be performed.
details provided in Supplementary Table 3, which can be viewed
online at www.journals.cambridge.org/thc2013090. Health Services Impact (Ethical, Legal, and Psychosocial)
Disease Burden Health services impact was discussed in seven studies
Most case studies considered disease burden as a criterion (5– (8;9;11;12;14;17;18). Ball et al. accounted for the impact on
11;14–18). One study estimated the disease burden with the legislation with changes to the mental health services in Norfolk
annual number of hospitalizations for chronic airway limitation Primary Care Trust (14), Spenceley et al. reviewed operational
(5), another study considered the prevalence and severity of res- considerations (11), and Lindström and Waldau applied an ethi-
piratory diseases and the annual number of respiratory-related cal framework to their decision process using accountability for
hospitalizations and mortality (17), the incidence of infertility reasonableness (18). The impact on workplace environment,
was accounted for in another study (18), and the incidence of application of new information or initiatives, and future health
vertebroplasties and number of procedures done in the lumbar services usage based on proposed changes in community ser-
was examined by the MSAC (6;7). Mitton et al. did not esti- vices provided in a metropolitan area were part of the criteria
mate the potential number of patients who would be impacted for discussion in one study (9). Three case studies considered
by the changes in surgical services in Canmore but stated that access, equity, acceptability, feasibility, and/or impact of imple-
approximately 700 procedures were performed in 2000/2001. mentation for the PBMA exercises (8;12;17).
Spenceley and Halma indicated the number of surgical proce-
dures performed in 1999/2000 (10;11). Carter et al. reported Stakeholder and Public Engagement
the population affected by cervical cancer screening and an- All studies incorporated an interdisciplinary advisory panel in
other study presented an approximate number of normal births the decision process. Panel members may have included exec-
in one health region (8;15). utives, directors, managers, clinical leads, physicians, special-
ists, radiologists, surgeons, nurses, researchers and academics,
Clinical Effectiveness and Patient Safety health economists, and social therapists. Ruta et al. surveyed
The clinical-effectiveness or health gains of the healthcare tech- health professionals in Tayside, Scotland, working with children
nologies and services that would be potentially impacted by to provide their ranking on service expansions and reductions
disinvestment decisions was factored explicitly in three reports based on a list derived from another working group (16). In
(10;12;16;18). One case study included impact on safety, ad- several instances, patient or community representatives partook
verse events, or harm reduction as criteria for disinvestment de- in the panel discussions and decision process (5–8;14;17;18).
cision making (13). Another case study reviewed the literature
on potential clinical benefits for various birth delivery strategies Sources of Data
(15). Five reports examined both the clinical-effectiveness and The clinical- or cost-effectiveness of an intervention or service
impact on safety and adverse events (6;7;9;14;17). One report was obtained from the published literature and clinical practice
measured the incidence, mortality, disability adjusted life-year, guidelines in eleven reports (5–8;10;11;15–18). Clinical expert
years lived with a disability, and years of life lost for proposed opinions were sought if there were evidence gaps (8;14;18). Cost
changes to cervical cancer screening strategies (8). data were obtained from local agencies, stakeholders, programs,

7 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013

Polisena et al.

regional health authorities, governments, and pharmaceutical Strengths and Limitations of Frameworks and Tools Based on Stakeholder
subsidy costs in several studies (6–8;14–17). If cost data were Feedback
unavailable, health services usage or prescription data were ob- In some instances, participants provided their feedback on the
tained to calculate the related costs in one study (13). Two case strengths and limitations of the disinvestment process mainly
studies did not specify any data sources used (9;12), and the through surveys or interviews once the recommendations and
source of cost data was not available in one study (18). decisions were set forth. Overall, the stakeholders found PBMA
to be a transparent and structured framework for resource allo-
Disinvestment and Resource Allocation Decision and Rationale. In most studies, the
cation decision making (8–10;14;17). Furthermore, the devel-
stakeholders agreed to the proposed changes on the reduction
opment of a set of criteria and identification of a program budget
or discontinued use of specific health technologies and inter-
clarified the opportunity costs associated with a disinvestment
ventions (5;6;9;10;12–14;16;18). Bohmer et al. reported that
proposal and helped to ensure that the health program’s objec-
adequate funds were found for investment opportunities in one
tives were met. The stakeholders also complimented the inclu-
health authority, so disinvestment was not necessary (17), and
sivity of diverse perspectives involved in the discussions, fol-
the MSAC recommended that AIDR continue to receive pub-
lowed by the development of recommendations (5;9;11;13;14).
lic funding because the clinical-effectiveness and safety were
Several limitations with the application of PBMA were
comparable to that of lumbar fusions, but the cost-effectiveness
noted. These limitations would be applicable to other frame-
results were mixed (7). The same committee recommended
works and tools for disinvestment decision making. First, the
against further funding for vertebroplasty and kyphoplasty be-
identification of appropriate disinvestment opportunities was a
cause the evidence indicated that it was no more clinically ef-
great challenge for some stakeholders, and there was uncertainty
fective but presented greater costs and risk for harms versus
on whether the correct decisions were made (5;9;10). Second,
conservative management (6;7). In the remaining case studies,
individuals, who are involved in the decision process, require
decisions regarding disinvestment recommendations were un-
training and sufficient time to ensure that the framework is exe-
clear. The primary reasons for a disinvestment or reduction in
cuted as intended (8;14;17). Insufficient clinical-effectiveness,
use of a technology or service were to release resources for
safety studies, or cost data were sometimes an impediment for
their reallocation to other services or programs deemed more
evidence-based recommendations (5;10;13;15;16). In some in-
beneficial by the stakeholders (5;10;14;16;21). In addition to
stances, decisions were based on assumptions or clinical ex-
clinical- and cost-effectiveness of infertility treatments, the de-
perience due to insufficient available data or evidence iden-
cision makers also reviewed the evidence on social and cultural-
tified. Finally, a structured approach for the implementation
specific criteria (18). Details on the disinvestment decision and
of and follow-up on the recommendations would ensure their
rationale are outlined in Supplementary Table 4, which can be
credibility and uptake (9;10;17). The strengths and limita-
viewed online at www.journals.cambridge.org/thc2013090.
tions on the use of HTA processes used by the MSAC to for-
Impact of Decision. Ten reports did not indicate the impact of the dis- mulate recommendations for vertebroplasty, kyphoplasty, and
investment decision (6–9;11;12;14;15;17;22). At the time of the AIDR were not available, although disinvestment recommenda-
publications, the recommendations had not been implemented tions on the former were subsequently implemented, suggest-
yet, so information on their impact in health care was not avail- ing program effectiveness (6;7). A complete list of strengths
able. In one instance, the recommendations for disinvestment and limitations extracted from each case study are presented
were implemented, but details were not available (12). Twaddle in Supplementary Table 5, which can be viewed online at
and Walker noted that fewer in-patient gynecological proce- www.journals.cambridge.org/thc2013090.
dures would contribute up to GBP400,000 of potential savings
based on 1992 prices (USD950,570 in 2012). Furthermore, re- DISCUSSION
source reallocation from dilations and curettes to endometrial
sampling or outpatient hysteroscopy would reduce costs by 50 Summary of Results
percent (13). Changes to the resource allocation for surgical ser- Fourteen case studies from the published literature that provided
vices in a community hospital would result in additional days examples of disinvestment and resource allocation processes
for minor surgery without increased costs (10). Lindström and in the health context were included in this review (5–11;13–
Waldau reported no adverse events associated with the imple- 18). Most described the application of PBMA at the regional
mentation of their resource reallocation recommendation for (9;12;13;15–18) or institutional level (5;10;11;14) and two re-
infertility treatments (18). Also, health services usage was re- ports used the HTA process (6;7). Our results indicate a potential
duced, such as the number of visits or consultations with a publication bias toward PBMA papers, so our Discussion will
physician, and contact between patients and healthcare provider reflect this occurrence.
was maintained through a designated Web site (18). One case The appropriateness of a framework or tool would depend
study indicated that preliminary findings of an increase in day on the number of interventions to be included and the healthcare
surgeries pointed to minimal cost impact (16). system context. The MSAC used the HTA process to review the

INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013 8

 Case studies on disinvestment and reallocation

interim funding of vertebroplasty and AIDR. These reviews approach, along with other methods to facilitate disinvestment
focused on specific technologies and comparators within a na- decisions, will be piloted in a Melbourne metropolitan hospital
tional fee-for-service system, while the other studies that used network in Australia (21).
PBMA examined the resource allocation for programs of care or
a consortium of interventions for a broader population. PBMA
LIMITATIONS
is adaptable to a regional or institution context with one program
Our systematic review identified 14 case studies in the published
budget and to a decentralized healthcare system with multiple
literature. Although the gray literature was searched to improve
budgets. Most case studies did not discuss the impact of their
the comprehensiveness of case studies on disinvestment and re-
recommendations because they had not yet been implemented
source allocation identified, the published literature may present
(6;7;9;14;17;22).
an overrepresentation of PBMA studies. We suggest that these
The specific application of A4R was illustrated in two case
case studies are a paltry representation of actual applications of
studies (12;18). This framework was applied to ensure the fair-
the frameworks and tools in the health context. The scope for this
ness of Sweden’s prioritization healthcare setting process in
systematic review was limited to illustrations of disinvestment
the review of infertility diagnostics and treatments (18). In ad-
and resource allocation processes using specific frameworks or
dition to the four conditions distinct to A4R (publicity, rele-
tools in the healthcare system in the published and gray liter-
vance, appeals mechanism, and enforcement), the disease bur-
ature. Numerous HTA agencies, including organizations in the
den, clinical- and cost-effectiveness, and opportunity costs of
United Kingdom, Australia, and Spain, have been active in dis-
the technologies and services were also examined. The authors
investment initiatives, but in all likelihood do not have a strong
did not mention any limitations to the process, and the disin-
mandate to publish their activities. Although the current sample
vestment decisions were well-received in the healthcare field
is not representative of all disinvestment activities undertaken
and at the political level (18). Urquhart et al. acknowledged that
by HTA agencies, this study intended to review case studies
not all A4R conditions, such as public involvement, were met
that illustrated different disinvestment examples in context. To
during their priority setting exercise (12).
ensure the comprehensiveness of the literature identified, the
Dionne et al. interviewed stakeholders who used PBMA
search timeframe spanned over 20 years, no language restric-
for reallocation decisions in the Vancouver Island Health Au-
tion was applied and the gray literature, including HTA agency
thority (23). Some issues faced by the stakeholders were the
Web sites, was included. Although HTA agencies may follow
establishment on the basis for which allocation decisions are
up on the decisions based on their analyses, as mentioned pre-
made, the comparisons of requests from distinct departments,
viously they typically do not publish this information. Possible
how decisions can be evidence-based, and how to ensure that
explanations may stem from the political sensitivities surround-
the decision process is fair (23). These concerns are consistent
ing resource reallocation decisions (24), as well as a low priority
with several limitations pointed to by the stakeholders in the
viewpoint and few incentives by decision makers to publish in
case studies. Some recommendation strategies to improve the
peer-reviewed journals, which is in contrast to PBMA, which
process are to train the panel advisory group on economic and
appears to be led by academics. Finally, it is unknown if the
ethical principles, the application of weights to decision crite-
recommendations were implemented in most case studies and
ria to reduce the subjectivity of the recommendations, and the
if so, their impact on patient care, health services delivery, and
review of investment and disinvestment opportunities with an
cost to the healthcare system.
external mandate by senior management (23).
The identification of disinvestment opportunities was a
challenge for some stakeholders. Reasons may include reluc- DIRECTIONS FOR FUTURE RESEARCH
tance to remove any interventions or an inclination to increase One limitation with the frameworks and tools relates to the
the provision of health services (24). To reduce barriers to disin- availability of data used to support an informed decision. Fu-
vestment and resource release with PBMA, Mortimer suggested ture research can examine the data requirements to support
that the identification of disinvestment candidates be compiled disinvestment decisions and address the development of data
before the identification of investment opportunities and the collection frameworks to fill the evidence gaps. The availability
risk of any oversight on disinvestment would be reduced. Fur- of this information would reduce the need for assumptions and
thermore, advisory groups with appropriate representation and resultant uncertainty with the decision process. Future studies
members can provide suggestions on investment and disinvest- also can measure the impact and potential unintended conse-
ment options for a defined program budget, subsequently these quences with the implementation of disinvestment decisions
options would be ranked according to input from healthcare and identify factors that contributed to the success and failures
providers or a tool for identification of priorities for disinvest- of the framework or tool.
ment (21). Mortimer recommended that the program budget in- A challenge with disinvestment is the identification and pri-
corporate all health services that would potentially be impacted oritization of candidate health technologies (25). The reduction
and present an explicit budget constraint (21). The proposed or removal of ineffective technologies can be passive or occur

9 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 29:2, 2013

Polisena et al.

through natural attrition, where the use of existing technologies Adam G. Elshaug, MPH, PhD, Department of Health Care
or procedures decreases in clinical practice over time with the Policy, Harvard Medical School, Boston, Massachusetts, School
introduction of new services. Triggers to initiate discussions of Population Health, The University of Adelaide
on disinvestment remain vague and barriers to disinvestment Craig Mitton, PhD, School of Population & Public Health, Uni-
processes merit further exploration. An opportunity to initiate versity of British Columbia, Centre for Clinical Epidemiology
discussions on disinvestment may coincide with the introduc- and Evaluation, Vancouver Coastal Health Research Institute,
tion of a new technology in the same class and, hence, would Vancouver, British Columbia, Canada
result in the existence of multiple technologies for the same in- Erin Russell, MSc, Canadian Agency for Drugs and Technolo-
dication. Signals from post-marketing surveillance data sources gies in Health, Ottawa, Ontario, Canada
on adverse events associated with the use of a healthcare tech- Becky Skidmore, MLS, Independent Researcher and Informa-
nology may serve as another catalyst for similar discussions. tion Specialist, Ottawa, Ontario, Canada
The support for data collection, once a health technology has
been approved for clinical practice, is low. Coverage with ev-
idence development, where provisional access is provided to CONFLICTS OF INTEREST
new and emerging technologies while evidence is generated to Julie Polisena has received a scholarship from University of
inform decisions on the future use of the technologies, as a Ottawa. Adam Elshaug is a Sidney Sax Fellow; his institution
disinvestment framework, warrants some investigation. receives consultancy fees from the Australian Government and
the Canadian Agency for Drugs and Technologies in Health
(CADTH). Becky Skidmore was hired by CADTH (Canadian
CONCLUSIONS Agency for Drugs and Technologies in Health) as consultant
Fourteen case studies illustrated the application of frameworks for this project. The other authors report they have no potential
and tools for disinvestment and resource allocation decisions in conflicts of interest.
various healthcare systems for an array of healthcare services
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