The challenge of disinvestment

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The challenge of disinvestment

• Kalipso Chalkidou
• Research and Development
• NICE

ESRC Seminar Series March 2007
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Good intentions

• With all the excellent developments in medicine
  that are becoming available, it is not in
  anyone's interest to waste money on treatments
  that do not provide good value for money NICE
  is going to provide authoritative advice to help
  us make the best use of the resources available
  to the NHS.
• Frank Dobson, Secretary of State for Health,
  speech launching NICE, March 1999
• ACTS Definitions and Criteria Does the proposed
  guidance relate to one or more interventions
  which could, without detriment to patient care,
  be used more selectively, thus freeing up
  resources for use elsewhere in the NHS?

ESRC Seminar Series March 2007
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Limited impact?

• There are some good examples
• appraisals on the removal of wisdom teeth and
  proton pump inhibitors
• guidelines on the management of heavy menstrual
  bleeding, caesarean section and LARC
• but
• Clear bias in favour of new technologies
• Few disinvestment topics actually referred to
  NICE
• Rationale for referral not explicitly stated in
  the guidance remit
• Limited evidence base for established treatments
• Resistance to withdrawing existing technologies

• National tariff uplift 2005/06 389m (0.9)
• Specific adjustments to HRGs
• approx 800-1,200m overall impact

ESRC Seminar Series March 2007
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Waste not, want not

• NICE should be
• asked to issue guidance to the NHS
• on disinvestment, away from established
• interventions that are no longer appropriate
• or effective, or do not provide value for money.
• CMO Annual Report, 2005
• "NICE has an excellent track record in
  identifying and recommending the most effective
  new treatments. But we need to ensure that we
  balance this with better advice on unnecessary
  and ineffective interventions that can be
  stopped."
• Andy Burnham, Sep 2006

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Can cost inflating be cost-effective?

• Develop cost-effective public health guidance
  reduce clinical need fully engaged scenario
• Set realistic threshold reflecting ICERs of
  services currently introduced or discontinued at
  the local level, assuming a rational
  prioritisation process, informed by economic
  evidence, exists
• Identify, evaluate and recommend against ongoing
  cost-ineffective practices set up a
  disinvestment agenda
• Influence strategic research priorities to reduce
  uncertainty and prevent decision reversal and
  sunk costs

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NICE disinvestment activities

• Recommendation reminders
• Commissioners guides
• Using existing NICE programmes
• Establishing dedicated disinvestment streams
• Topic selection
• A disinvestment related research agenda
• Working with external partners

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Recommendation Reminders

• Existing NICE guidance
• Still relevant to the NHS clinical expert input
• Additional costing tools
• Over 250 single do not do recommendations
  between 1999-2005
• Lesson 1 the press release matters!
• Lesson 2 baseline hard (impossible?) to define
  lack of data
• Lesson 3 some people do not want to be reminded

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Commissioners Guides

• Not dedicated disinvestment tool
• Aimed at supporting evidence-based effective
  commissioning
• Building on NICE costing tools/budget impact
  analysis
• Examples upper GI endoscopy, foot care for
  diabetes, anticoagulation, management of COPD
• Commissioning guides are not
• advice on how to commission
• new formal NICE guidance
• fixed can be adjusted to local setting
• Web-based accessible to PCTs and practices in
  England

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Topic selection

• Increased responsibility of NICE in topic
  selection
• No separate disinvestment consideration panel
• Consider
• variation in practice,
• current usage and potential real savings,
• substitute technology/pathway,
• feasibility of change in practice,
• effect on inequalities(?)
• Sometimes, disinvestment topics result in
  investment recommendations

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Using existing NICE programmes

• Target wasteful practice at the scoping stage
• Encourage guidance developers to think about
  waste
• Improve communication of do not do
  recommendations
• PET, structural MRI, magnetic resonance
  volumetry and magnetic resonance spectometry
  should not be used in the differential diagnosis
  of parkinsonian syndromes, except in the context
  of clinical trials. Parkinsons disease, NICE
  Clinical Guideline, London, June 2006
• The use of multi-channel cystometry, ambulatory
  urodynamics or videourodynamics is not
  recommended before starting conservative
  treatment. The management of urinary
  incontinence in women, NICE Clinical Guideline,
  London, October 2006

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New disinvestment streams

• Same methodology of economic evaluation
• Focus on identification of relevant topics
• Key areas
• Service reconfiguration but the evidence base
  is different
• Inappropriate use of antibiotics chloramphenicol
  for conjunctivitis, tetracyclines for acne and
  topical corticosteroid/antimicrobial combinations
• Grommets
• Diagnostic tests

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Research and disinvestment atopic eczema

• What we said
• It is recommended that topical corticosteroids
  should be prescribed for application only once or
  twice daily.
• What we do not know
• Is once-daily use of the older twice-daily
  products equivalent to the once-daily-only
  products of the same potency?
• What we said
• Topical tacrolimus and pimecrolimus are not
  recommended for the treatment of mild eczema or
  as first-line treatments for eczema of any
  severity.
• What we do not know
• What are the long-term effects of tacrolimus and
  pimecrolimus?
• How do these drugs compare with appropriate
  potencies of topical corticosteroids?

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Cooksey Report

• The Review recommends that funding be identified
  and formal arrangements be established between
  NHS RD and NICE in order to implement NICE
  recommendations calling on the NHS to use health
  interventions in a research context
• Value-based pricing for new technologies
• Continuous evaluation through registries and
  databases for established treatments
• Implementation of public health and clinical
  guidelines recommendations only in research
• Methods for developing disinvestment guidance

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Partner organisations

• Cochrane Collaboration
• Association of Public Health Observatories
• NHS Institute
• NHS information centre and other databases
• Welsh HIRU

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The challenges of substitution
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Evidential and methodological

• Selecting the right topics
• What is the comparator?
• Weak evidence base for established treatments
• Guidance developers reluctant to stop current
  practice
• No sponsor and little incentive for more
  research
• Are savings real(isable)?
• Economic vs costing model defining opportunity
  cost
• Extrapolating over long time horizons
• Establishing the baseline

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Implementation

• What happens with the savings Choosing Health vs
  chemo?
• The kinkiness of the SW quadrant
• NICE-specific
• Centralised advise often insensitive to local
  setting
• NICE does not look at everything what about
  activities below the baseline?

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and other!

• Single technology appraisal getting the
  comparator/timing right
• Substituting new technologies for preventative
  interventions lowering the threshold?
• 3 month implementation directive and the
  health-wealth trade-off

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Way forward

• NICE can
• Help manage pressures
• Trigger a public debate and help bring about a
  mentality change
• Encourage necessary research and evidence
  generation
• Produce more evidence-based disinvestment advice
  and less budget-inflating recommendations
• But we can do more

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How can NICE really add value?

• Empower commissioners and consumers (PCTs,
  GPspatients)
• Provide access to
• evidence-based
• need-adjusted
• comparative rates for benchmarking
• Elicit patient and professional input
• Move away from centralised intervention-specific
  do not do guidance
• commissioners' guides
• tailored guidance (?)
• evidence base for contract exclusion agenda (?)

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Its the data,!
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surgery drugs diagnostics disease
management prevention health promotion
NICE guidance
Guidance development stages

• Topic selection
• Scoping
• Guidance development
• Evidence gaps
• Budget impact
• Implementation support
• Guidance review
• Guidance uptake and impact assessment

BoD, variation, evidence base, trend
data Prevalence/incidence, current practice,
comparators Baseline risk, resource use, QoL,
long-term follow up, subgroup analysis,
generalisability of effect Ongoing studies,
only in research when high uncertainty, high
priority research questions Unit costs, PCT/SHA
demographics, service activity, prescribing and
workforce data Examples of good practice,
existing networks, relevant policy
initiatives New evidence on long term costs,
efficacy, safety, alternatives Prescribing (by
indication) and activity data, barriers,
frontline substitution threshold, relating
spending to health outcomes
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Lack of datastill useful?

• Evidence of lack of effectiveness vs lack of
  evidence of effectiveness
• Inform strategic research priorities
• Support commissioning

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CEA in the NICE context is not a panacea

• We need access to longitudinal data on variation
  coupled with robust local prioritisation
  processes
• Fisher et al, Ann Intern Med, 2003 Skinner et
  al, Health Affairs, 2006

• NICE has operated during the halcyon days of an
  unprecedented period of sustained growth in the
  overall NHS budget, a rate of growth that cannot
  continue indefinitely. When budgets cease to
  grow, a new day will dawn for NICE and the NHS as
  they manage the delicate balance between
  cost-effective new technologies and local health
  authority budgets.
• Pearson and Rawlins, JAMA, November 2005

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Thank you!
ESRC Seminar Series March 2007