It’s not as simple as new for old: we need to follow a process for “disinvestment” in existing medical procedures, services and technologies
Criteria have been developed for assessing the safety, effectiveness and cost-effectiveness of new and emerging health interventions, but additional challenges exist in identifying opportunities for reducing the use of existing health technologies or procedures that are potentially overused, (cost-)ineffective or unsafe.1 Criteria have been proposed to flag technologies that might warrant further investigation under quality improvement programs.1 These criteria are: new evidence becomes available; there is geographical variation in use; variation in care between providers is present; the technology has evolved and differs markedly from the original; there exists a temporal trend in the volume of use; public interest or controversy is present; consultation with health care workers and funders raises concerns; new technology has displaced old technology; there is evidence of leakage (use beyond the restriction or indication); the technology or intervention is a “legacy item” that has never been assessed for cost-effectiveness; use is not in accordance with clinical guidelines; or the technology is nominated by clinical groups.
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- 1. Elshaug AG, Moss JR, Littlejohns P, et al. Identifying existing health care services that do not provide value for money. Med J Aust 2009; 190: 269-273. <MJA full text>
- 2. Willis CD, Elshaug AG, Milverton JL, et al; ASTUTE Health Study Group. Diagnostic performance of serum cobalamin tests: a systematic review and meta-analysis. Pathology 2011; 43: 472-481.
- 3. Stabler SP. Vitamin B12 deficiency. N Engl J Med 2013; 368: 149-160.
- 4. Carmel R, Agrawal YP. Failures of cobalamin assays in pernicious anemia. N Engl J Med 2012; 367: 385-386.
- 5. Carmel R. Biomarkers of cobalamin (vitamin B-12) status in the epidemiologic setting: a critical overview of context, applications, and performance characteristics of cobalamin, methylmalonic acid, and holotranscobalamin II. Am J Clin Nutr 2011; 94: 348S-358S.
- 6. Galloway M, Rushworth L. Red cell or serum folate? Results from the National Pathology Alliance benchmarking review. J Clin Pathol 2003; 56: 924-926.
- 7. Brown RD, Langshaw MR, Uhr EJ, et al. The impact of mandatory fortification of flour with folic acid on the blood folate levels of an Australian population. Med J Aust 2011; 194: 65-67. <MJA full text>
- 8. Shojania AM, von Kuster K. Ordering folate assays is no longer justified for investigation of anemias, in folic acid fortified countries. BMC Res Notes 2010; 3: 22.
- 9. Medicare Australia. MBS items statistics reports. https://www.medicare australia.gov.au/statistics/mbs_item.shtml (accessed Sep 2010).
- 10. National Institute for Health and Clinical Excellence. Dementia: supporting people with dementia and their carers in health and social care. NICE clinical guideline 42. London: NICE, 2006. http://guidance.nice.org.uk/CG42 (accessed Mar 2013).
- 11. Turnbull N, Shaw EJ, Baker R, et al. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management of chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy) in adults and children. London: Royal College of General Practitioners, 2007.
- 12. The Royal College of Pathologists of Australasia. RCPA manual [online searchable manual]. 2009. http://www.rcpamanual.edu.au (accessed Mar 2013).
- 13. Best Practice Advocacy Centre New Zealand. Laboratory investigation of tiredness. Dunedin: bpacnz, 2006. http://www.bpac.org.nz/resources/campaign/tiredness/tiredness_poem.asp (accessed Mar 2013).
- 14. Guidelines and Protocols Advisory Committee. B12 deficiency — investigation and management of vitamin B12 and folate deficiency. Victoria, British Columbia: Canadian Ministry of Health, 2006.
- 15. Bayram C, Britt H, Miller G, Valenti L. Evidence-practice gap in GP pathology test ordering: a comparison of BEACH pathology data and recommended testing. Sydney: University of Sydney, School of Public Health, 2009.
- 16. Whiting P, Toerien M, de Salis I, et al. A review identifies and classifies reasons for ordering diagnostic tests. J Clin Epidemiol 2007; 60: 981-989.
The Assessing Service and Technology Use To Enhance Health (ASTUTE Health) study, within which vitamin B12 and folate blood tests are a case study, is funded by the National Health and Medical Research Council (NHMRC grant 565327). The findings and views expressed in this article are those of the authors and do not necessarily represent those of the Commonwealth Fund. Cameron Willis and Adam Elshaug hold NHMRC Fellowships (1013165 and 627061, respectively). Cameron Willis was supported by funding from the NHMRC Health Care in the Round Capacity Building Grant (565501). We acknowledge the valuable contributions made by Amber Watt, Dagmara Riitano and Heather Buchan. We also acknowledge the contributions made by the ASTUTE Health study group: Annette Braunack-Mayer, John Moss, Jackie Street, Tracy Merlin and Jonathan Karnon.
Janet Hiller and Adam Elshaug are Co-Chief Investigators, Michael Metz is an Associate Investigator, and Cameron Willis is a former Senior Research Fellow of the ASTUTE Health study. Adam Elshaug and Janet Hiller contribute to the Australian Government Department of Health and Ageing’s Safety, Quality and Sustainability Forum and the Comprehensive Management Framework for the Medicare Benefits Schedule. Vitamin B12 and folate blood tests have been selected for review within that framework. Janet Hiller is a member of the Protocol Advisory Sub-Committee of the Medical Services Advisory Committee.