Objectives: In the past decade, there has been a growing interest in health technology disinvestment. A disinvestment process should involve all relevant stakeholders to identify and deliver the most effective, safe, and cost-effective healthcare interventions. The aim of the present study was to describe the state of the art of health technology disinvestment around the world and to identify parameters that could be associated with the implementation of disinvestment programs.

Methods: A systematic review of the literature was performed from database inception to November 2014, together with the collection of original data on socio-economic indicators from forty countries.

Results: Overall, 1,456 records (1,199 from electronic databases and 257 from other sources) were initially retrieved. After analyzing 172 full text articles, 38 papers describing fifteen disinvestment programs/experiences in eight countries were included. The majority (12/15) of disinvestment programs began after 2006. As expected, these programs were more common in developed countries, 63 percent of which had a Beveridge model healthcare system. The univariate analysis showed that countries with disinvestment programs had a significantly higher level of Human Development Index, Gross Domestic Product per capita, public expenditure on health and social services, life expectancy at birth and a lower level of infant mortality rate, and of perceived corruption. The existence of HTA agencies in the country was a strong predictor (p = .034) for the development of disinvestment programs.

Conclusions: The most significant variables in the univariate analysis were connected by a common factor, potentially related to the overall development stage of the country.

Seven consensus development conferences have been held in Sweden since 1982. The conferences, sponsored by the Swedish Medical Research Council and Spri, typically examine social, organizational, and economic aspects of technology, and therefore, generate consensus statements of interest not only to physicians but also to politicians and health administrators.

The study presented here examines the influence of the first five consensus development conferences on politicians and health administrators. Data was obtained via a mail questionnaire and personal interviews with leading individuals in these groups. More than half of the respondents indicated that they had found the statements from one or more conferences to be of practical value as a basis for discussing specific technologies with medical staffs. In some cases the statements directly influenced political decisions.

This paper describes a content analysis of the statements of 24 Consensus Development Conferences conducted by the Office of Medical Applications of Research (OMAR) of the National Institutes of Health in the years 1979–1983. The goal was to understand the potential influence of the consensus statements by identifying characteristics that might determine whether and how physicians become aware of their findings and adopt their recommendations. Three characteristics emerged, each suggestive of a different style of consensus statement: discursiveness, didacticism, and scholarliness. Variations in style among consensus statements may affect their acceptance by the medical profession

Objectives: The study aims to develop an understanding of the views of children and adolescents, parents, and professionals on upper limb prosthetic devices to develop and improve device design. Previous research has found that children are dissatisfied with prostheses but has relied heavily on parent proxy reports and quantitative measures (such as questionnaires) to explore their views.

Methods: Thirty-four participants (eight children aged 8–15 years with upper limb difference, nine parents, eight prosthetists, and nine occupational therapists) contributed to the development of new devices through the BRIDGE methodology of participatory design, using focus groups and interviews.

Results: The study identified areas for improving prostheses from the perspective of children and adolescents, developed prototypes based on these and gained feedback on the prototypes from the children and other stakeholders (parents and professionals) of paediatric upper limb prostheses. Future device development needs to focus on ease of use, versatility, appearance, and safety.

Conclusions: This study has demonstrated that children and adolescents can and should be involved as equal partners in the development of daily living equipment and that rapid prototyping (three-dimensional printing or additive manufacturing), used within a participatory design framework, can be a useful tool for facilitating this.

Objectives: To apply the Theory of Constraints (TOC) to the Evidence-based Practice Center (EPC) process.

Methods: Participants in the EPC process were interviewed, and the technical contracting literature was reviewed. Undesirable effects (UDEs) that might occur in the EPC process were identified and, in a TOC Current Reality Tree (CRT), a fundamental UDE was selected and tracked back to potential root causes, focusing on the core “constraint.” The resulting draft CRT was presented at an EPC directors' meeting and finalized. From possible solutions obtained from interviews and literature, a Future Reality Tree (FRT) was constructed.

Results: Three UDEs were identified and that a report is not used was deemed fundamentally undesirable. Nine root causes were identified, and using the CRT, a core constraint emerged: EPC partner does not know how to conceptualize and articulate needs, objectives, and specifications. Two change strategies (“injections”) appeared to address the core constraint: establish an ongoing relationship between partners, EPC, and Agency for Healthcare Research and Quality early in the process, and use a changes clause; in a FRT the injections lead to the positive outcome—the production of a successful EPC report that meets partner needs and, therefore, will be used.

Conclusions: As with any complex enterprise, the EPC needs to engage in self-reflection and active improvement to maximize its value. The development of technical reports intended to inform decision making represents a complicated area, involving a network of interrelated processes. Using the TOC permitted us to understand process failures; results serve as a guide to improvement.

Objectives: The overall objective of this article was to review the theoretical and conceptual dimensions of how the implementation of clinical practice guidelines (CPGs) is likely to affect treatment costs.

Methods: An important limitation of the extant literature on the cost effects of CPGs is that the main focus has been on clinical adaptation. We submit that the process innovation aspects of CPGs require changes in both clinical and organizational dimensions. We identify five organizational factors that are likely to affect the relationship between CPGs and total treatment costs: implementation, coordination, learning, human resources, and information. We review the literature supporting each of these factors.

Results: The net organizational effects of CPGs on costs depends on whether the cost-reducing properties of coordination, learning, and human resource management offset potential cost increases due to implementation and information management.

Conclusions: Studies of the cost effects of clinical practice guidelines should attempt to measure, to the extent possible, the effects of each of these clinical and organizational factors.

Clinical practice guidelines have been available to clinicians for almost two decades, but the consistency of their implementation in practice remains highly variable. This paper describes the various processes and mechanisms used by one managed care organization to develop clinical guidelines and promote their adoption. Some of these mechanisms include provision of individual physician report cards, financial incentives, and various documentation tools that serve as reminders of guideline recommendations and provide an easy format to document recommended services.

There have been measurement challenges in evaluating the effectiveness of selected interventions designed to enhance guideline compliance. Most of these challenges relate to reliability and validity concerns regarding the three primary data sources used in the evaluation process: medical records, administrative claims data, and member survey data. Some of the interventions the health plan has implemented to address these measurement challenges include using hybrid methods of data collection and developing collaborative partnerships with outside organizations to enhance the accuracy and completeness of the available data. Outcomes of these efforts are described, as are physician response and recommendations for future enhancement of practice guidelines.

Objectives: The objectives of this study were to identify and qualitatively describe, in a systematic literature review, published studies that collected prostate cancer patients’ health-related quality of life (HRQoL) estimates by using validated, generic instruments.

Methods: Systematic searches of the literature were made using the Medline, Cochrane Library, PsycINFO, and CINAHL electronic databases from 2002 to 2015.

Results: The search identified 2,171 references, of which 237 were obtained for full-text assessment; thirty-three of these articles were deemed relevant and included in the systematic review. An indirect valuation method was used in 73 percent (n = 24) of the studies. The most commonly used HRQoL instrument with an indirect valuation method was the EuroQol (EQ-5D; n = 21), and the second most common was the 15D (n = 5). A direct valuation method was used in 48 percent (n = 16) of the studies. Of these, the Visual Analogue Scale (VAS) was the most often used (n = 10), followed by the Time-Trade-Off (n = 6). HRQoL scores varied in localized and early stage disease between 0.63 and 0.91, and in advanced or metastatic disease stage between 0.50 and 0.87. There was also variance in the HRQoL instruments and study methods used, which explains the large variance in HRQoL scores between the various disease stages.

Conclusions: Although utility and quality-adjusted life-years gained are considered important measures of effectiveness in health care, the number of studies in which utilities of prostate cancer patients have been estimated using generic HRQoL instruments, based on either direct or indirect measurement of HRQoL, is fairly small.

Introduction: Hospital-based health technology assessment (HB-HTA) has been introduced to help hospital management in decision making about the adoption of new health technologies (HTs). We reviewed the accuracy of the expected medical impact of HTs assessed at our hospital, as well as the acceptance of this process by clinicians.

Methods: For each HT adopted between 2002 and 2011, a semi-structured interview with the involved clinician was conducted, assessing (i) the perceived utility of the HB-HTA process, (ii) the accuracy of the new HT's expected medical impact as compared with observed patient data from the year 2012, and (iii) the compliance with the indications of the HB-HTA report.

Results: Over the 10-year period, forty HB-HTAs were carried out, of which thirty-four led to acceptance. Twenty-seven of the twenty-eight clinicians involved in these thirty-four HTs accepted the interview and 85 percent acknowledged the utility of the HB-HTA process. Five of the thirty-four HTs were no longer in use. For the twenty-nine remaining HTs, observed patients’ number was as expected in eight, higher in four, lower in fifteen, and not available in two cases. Available average length of stay was 61 percent longer than expected. Two HTs had a higher complication rate and three a lower success rate. Indications evolved in 55 percent of HTs after a few years (seven restrictions, six broadenings, and three other changes).

Conclusions: A HB-HTA process is useful to improve quality in decision making. Follow-up analysis should routinely be performed to adapt HB-HTA reports’ conclusions to practical experience and new scientific evidence.

Background: Clearly the benefits of a treatment must not be outweighed by the adverse effects. If researchers fail to incorporate adverse effects adequately in models, this could limit the validity of the results obtained. In the worst case, interventions that are cost-effective may be shown not to be. The aim of this research was to review current practice when incorporating adverse effects in economic models.

Methods: A survey of HTA reports commissioned by the National Institute for Health Research (NIHR) Health Technology Assessment programme, published between 2004 and 2007 was conducted. All reports which investigated the clinical and cost-effectiveness of a health technology using a systematic review and an economic model framework were included.

Results: A total of eighty reports met the inclusion criteria. Of the models including adverse effects (43/80), 67 percent used a clinical adverse effects parameter, 79 percent a cost of adverse effects parameter, 86 percent used one of these, and 60 percent used both. Of the thirty-seven models that did not include adverse effects, eighteen justified this omission, most commonly lack of data; nineteen appeared to make no explicit consideration of adverse effects in the model.

Conclusions: In many cases, poor reporting made it difficult to ascertain if there had been any consideration of adverse effects. We suggest that the findings of this survey support a call for much clearer and explicit reporting of adverse effects, or their exclusion, in decision models and for explicit recognition in future guidelines that “all relevant outcomes” should include some consideration of adverse events.

Health technology assessment (HTA) is increasingly used around the globe to inform resource allocation decisions. Furthermore, the importance of using explicit and transparent criteria for coverage decision making in line with health system values has been acknowledged. However, the values of a health system are often not explicitly taken into account in the HTA process. This situation influences the allocation of scarce resources and could lead to a discord between the HTA outcome and the values of the health system. We describe how evidence-informed deliberative processes (EDPs) can help to improve this situation. EDPs are integrating two theoretical frameworks; multi-criteria decision-analysis and accountability for reasonableness. Through the use of EDPs, HTA agencies can ensure that health system values are more explicitly and consistently taken into account in the HTA process, enhancing the legitimacy of coverage decisions.

The Dutch healthcare system is not a single overall plan, but has evolved from a constantly changing mix of institutions, regulations, and responsibilities. The resulting system provides high-quality care with reasonable efficiency and equal distribution over the population. Every Dutch citizen is entitled to health care. Health insurance is provided by a mix of compulsory national insurance and public and private insurance schemes. Hospitals generally have a private legal basis but are heavily regulated. Supraregional planning of high-tech medical services is also regulated. Hospitals function under fixed, prospective budgets with regulation of capital investments. Independent general practitioners serve a gatekeeper role for specialist and hospital services and are paid by capitation or fee for service. Specialists are paid by fee for service. All physicians' fees are controlled by the Ministry of Economic Affairs. Coverage of benefits is an important method of controlling the cost of services. There is increasing concern about health care quality. Health technology assessment (HTA) has become increasingly visible during the last 15 years. A special national fund for HTA, set up in 1988, has led to many formal and informal changes. HTA has evolved from a research activity into policy research for improving health care on the national level. In 1993 the government stated formally that enhancing effectiveness in health care was one of its prime targets and that HTA would be a prime tool for this purpose. The most important current issue is coordination of HTA activities, which is now undertaken by a new platform representing the important actors in health care and HTA.

Objective: To define the relative benefits of screening for diabetes and improved treatment programs and ways of improving the efficiency of screening for a population-based cohort derived from the Third National Health and Nutrition Examination Survey (NHANES III).

Methods: A Markov decision model is used to estimate microvascular benefits of glucose control for four different screening and treatment scenarios, including either universal screening or improved glucose control of known diabetic subjects, neither, or both.

Results: A population cohort of subjects with recent onset of diabetes (<5 years) was derived from NHANES III (of whom close to half were unaware that they had diabetes). In this population-based cohort, the total benefit achievable by universal screening and improved treatment (limiting HbA1c to less than 9%) is a reduction of about 30,000 cases of blindness over the lifetime of the cohort. Screening alone results in 7% of this benefit, and improved treatment alone provides 65%. Screening a targeted group of patients with three or more risk factors for developing diabetes would reduce the number of required fasting glucose measurements needed by 82% and provide 50% of the total benefit of screening the entire population with a fasting glucose measurement.

Conclusions: Morbidity from type 2 diabetes can be most effectively reduced by developing ways to modestly improve the glycemic control of known diabetic subjects, particularly those with high A1c's and early onset of disease. Targeting can significantly reduce the number of persons who need to be screened with a fasting blood test while preserving a large component of the benefit of screening.

Objectives: To describe health technology assessment (HTA) and policies concerning three screening procedures in Sweden.

Methods: The main source of information was reports from the Swedish Council for Technology Assessment in Health Care (SBU) and other governmental reports, supplemented by the professional literature.

Results: Prevention is emphasized in the healthcare services of Sweden. Specifically, screening is encouraged and supported when it is deemed beneficial. Sweden has a strong orientation toward evidence-based health care and HTA. Since its inauguration in 1987, SBU has fostered the use of HTA in making policy and clinical decisions in Sweden. Government policy in Sweden is to encourage services that are beneficial and cost-effective and discourages services that are not. Screening is no exception to this general rule. The three cases examined in this paper—mammography screening, PSA screening, and routine ultrasound screening in pregnancy—have all been formally assessed in Sweden. Assessments have been an integral part of policy making concerning these and other preventive measures. Mammography screening has been widely implemented. However, as in other countries, screening is often carried out in an opportunistic fashion, so that PSA screening, in particular, is carried out more in Sweden than can be justified by the evidence.

Conclusions: Mammography screening is promoted and is completely available to the target group. PSA screening is discouraged, but not with complete success. Ultrasound in pregnancy is widely used, not because of good evidence of impact on mortality and morbidity among newborns, but because it increases the detection rate of congenitally malformed fetuses and because of evidence of positive effects on the management and planning of deliveries, as well as because of psychological and ethical implications of the technology. HTA is an important part of health policy making in Sweden.