Table 3.
Examples of frameworks and models related to disinvestment
| Framework/Model | Setting | Aims | Method of development | Components |
|---|---|---|---|---|
| PROJECTS TO IDENTIFY AND DISINVEST INDIVIDUAL TCPS | ||||
| Framework of potential settings and methods for disinvestment [5] | Organisation-wide program in local health service network | To identify potential settings and methods for disinvestment decision-making within local health service systems and processes | Literature review; survey of external experts, interviews and workshops with local stakeholders | Three organisational contexts that provide potential opportunities to introduce disinvestment decisions into health service systems and processes are presented in order of complexity, time to achieve outcomes and resources required: 1. Explicit consideration of potential disinvestment in routine decision-making for purchasing and procurement and development of guidelines and protocols, 2. Proactive decision-making about disinvestment driven by available evidence from published research and local data, 3. Specific exercises in priority setting and system redesign. |
| Algorithm for selecting a disinvestment project from a catalogue of potential opportunities [9] | Organisation-wide program in local health service network | To facilitate decision-making for identification of potential and selection of actual disinvestment projects | Literature reviews; surveys, interviews and workshops with local stakeholders; document analysis; consultation with experts; taxonomy development | Five steps in selection process: 1. Assess highest risk, 2. Assess importance and potential, 3. Assess quality and strength of evidence, 4. Assess extent of problem, 5. Assess implications of change. Three key decision-making steps between Steps 2 and 3, 3 and 4, and after 5. After selection: Notify decision; Implement; Evaluate; Report Each step includes the activities, who will undertake them, and the decision options |
| Model for an Evidence Dissemination Service [11] | Organisation-wide program in local health service network | To facilitate use of recently published synthesised evidence in organisational decision-making | Literature reviews; surveys, interviews and workshops with local stakeholders; document analysis; consultation with experts; taxonomy development | Methods and tools to identify sources of high quality synthesised evidence; automate methods of capture; classify, collate and store materials in useful categories; prioritise based on user and health service needs; repackage into suitable formats based on user needs; identify relevant individuals or groups to receive information; disseminate to the appropriate target groups, and report use of evidence |
| Guideline for Not Funding Health Technologies (GuNFT) [35] | Two versions are provided, one for application at national and regional level and the other at local level. | To facilitate establishment of a transparent, systematic and explicit process for assessing the potential for disinvestment in certain health technologies or in some of their indications | Literature review; face-to-face meeting, teleconference and emails using Nominal Group Technique with 10 experts representing health care delivery, administration, technology assessment and consumers to draft the guideline; validation by two external experts in HTA; wide circulation for comment and approval | Seven phases: 1. Identification through applications; 2. Validation of applications; 3. Prioritisation (if necessary); 4. Assessment; 5. Decision making; 6. Development of an action plan; 7. Diffusion of the decision, the reasons why it has been taken and the action plan. Applications are submitted by health care professionals; validation, prioritisation and assessment of the applications are undertaken by a HTA agency or the health service Technology Assessment Committee; and the decision, development of the action plan and diffusion is undertaken by the health service or regional health authority management team or other multidisciplinary body. Tools are available. |
| Disinvestment framework to guide resource allocation decisions in health service delivery [16] | Health service delivery organisations | To aid disinvestment activity in the local setting. | Thematic analysis of systematic review and a scoping review of the public sector and business literatures. Draft framework critiqued by Decision Maker Advisory Committee (Chief Financial Officers from Canadian health services) and External Reference Group (international academics) before being finalised. | Seven steps: 1. Determine objectives and scope; 2. Identify strategic priorities; 3. Identify options and risk; 4. Rank options; 5. Develop implementation plan; 6. Conduct disinvestment; 7. Assess outcomes and processes. Oversight Committee (senior managers and clinical leaders) is responsible for the majority of the process components including making final decisions; independent Assessment Committee (managers, clinicians, other staff and public representatives) defines the criteria, weights and scale used to assess disinvestment options, Support Committee (researchers and financial personnel) assists in the assessment of disinvestment options in the form of evidence, financial analysis and evaluative measures. |
| PROGRAMS FOR SECTOR-WIDE INVESTMENT AND DISINVESTMENT | ||||
| Framework of components in the resource allocation process [6] | Organisation-wide program in local health service network | To represent components in the process of resource allocation and the relationships between them | Interviews and workshops with stakeholders, thematic analysis of responses, document analysis, use of existing frameworks to synthesise findings | Eight components: Governance, Administration, Stakeholder engagement, Resources Decision Making, Implementation, Evaluation, and, when appropriate, Reinvestment. Details of elements of structure and practice within each component is provided. Structure is described as ‘who’ and ‘what’ and includes people, systems, policies, requirements, relationships and coordination. Practice addresses ‘how’ through processes, procedures, rules, methods, criteria and customs. |
| Model for Sustainability in Health care by Allocating Resources Effectively (SHARE) [8] | Organisation-wide program in local health service network | To develop, implement and evaluate organisation-wide systematic, transparent, accountable and evidence-based decision-making systems and processes | Three literature reviews; online survey, interviews and structured workshops with stakeholders; consultation with experts in disinvestment, health economics and health program evaluation; drafted in consultation with staff, consumers and external experts; assessed against framework for success and sustainability | Four components, each with multiple elements: 1. Systems and processes; 2. Disinvestment projects; 3. Support services; 4. Program evaluation and research. The model outlines each component and the relationships between them, their aims and activities as well as the underlying principles and the preconditions required for success and sustainability. There is also detailed discussion of the antecedents, barriers and enablers. |
| New Zealand National Health Committee Workplan [36] | National government decision-making | To provide the Minister of Health with recommendations for use and funding of health technologies | Not documented | The program addresses which technologies should be publicly funded, to what level and where technology should be provided and how new technology should be introduced and old technology removed. Six phases: 1. Identification, 2. Prioritisation, 3. Analyse and Assess, 4. Recommend, 5. Implement, 6. Evaluate. |
| Health technology reassessment and decommissioning framework/model [37] | National or provincial government decision-making | To create a model for assessing the health technology life cycle to identify and delist obsolete technologies | Focused narrative literature review and input from experts. | Two components: 1. Health technology life cycle and reassessment, 2. Reassessment and Decommissioning Model, with Oversight Committee, Triggers, and Possible Outcomes. Second component includes triggers and processes, structure (oversight committee), decisions and outcomes |
| PROGRAM EVALUATION | ||||
| Framework for evaluation of priority setting [39] | National, regional and individual healthcare facilities | To develop a framework for the evaluation of priority setting practice at macro and meso levels | Literature review and thematic analysis | Two evaluation domains: 1. Consequentialist outcomes: Efficiency, Equity, Stakeholder satisfaction, Stakeholder understanding, Shifted (reallocation of resources), Implementation of decisions, 2. Proceduralist conditions: Stakeholder engagement, Empowerment, Transparency, Revisions, Use of evidence, Enforcement, Community values |
| SHARE Program Evaluation Framework and Plan [8] | Organisation-wide program in local health service network | To assess the effectiveness of the SHARE program, implementation fidelity and factors for successful change | Drafts prepared by project team in consultation with Consultant in Health Program Evaluation to meet the information needs of key stakeholders and the internal capacity of staff conducting the project; revised and finalised in consultation with key stakeholders | Seven evaluation domains: 1. Improved patient care, 2. Improved resource allocation for health technologies and clinical practices, 3. Improved decision-making, 4. Improved staff capacity in use of evidence and data in decision-making and implementation of practice change, 5. Barriers and enablers, 6. Implementation fidelity, 7. Sustainability and spread. Includes an outcomes hierarchy based on the SHARE program components and a research program based on a theoretical framework for implementation of an evidence-based innovation. |
| Framework for evaluation and explication of the processes and outcomes of a disinvestment project [9] | Organisation-wide program in local health service network | To adapt a framework and taxonomy for evaluation of evidence-based innovations to enable evaluation and explication of disinvestment projects | Literature review, surveys and interviews with stakeholders | Three components: 1. Determinants of effectiveness (characteristics of external environment, organisation, proposal for change, rationale and motivation, potential adopters, potential patients, identification process, prioritisation and decision-making process, implementation plan, implementation resources); 2. Process of change (delivery of implementation strategy and stages of change); 3. Outcomes (process and impact for patient, practitioner, systems, economic, reinvestment, sustainability and spread). Taxonomy containing details within each component is provided. |
| Integrative framework for measuring overuse [38] | Relevant settings within health care systems | To assess the impact of efforts to reduce low-value care. | Not documented | Provides list of measurement tools linked to specific project/program goals and discusses advantages and disadvantages of each approach |
| STAKEHOLDER ENGAGEMENT | ||||
| SHARE model for incorporating consumer views into decisions for resource allocation [7] | Organisation-wide program in local health service network | To involve consumers in organisation-wide decision-making, capture their perspectives and incorporate them into decisions for resource allocation. | Literature review, individual and group interviews with Consumer Working Group and health service staff, workshop with Community Advisory Committee, drafting and revision with consumer participation. | Four components: 1. Principles, 2. Scope, 3. Preconditions, 4. Activities Activities include Consumer engagement (communication, consultation and participation) and use of Consumer evidence (consumer perspectives found in publications and data sources). Details of activities are reported in the context of the components of the resource allocation process noted above |
| New Zealand National Health Committee Workplan [36] | National government decision-making | To seek advice and engage with the health sector | Not documented | Tiered approach to engage with and seek advice from clinicians via colleges and specialty societies; providers such as District Health Boards, NGOs and private facilities via Health Sector Forum; international Health Technology Assessment agencies; Universities and Research Institutes, international and domestic manufacturers. |