Disinvestment in healthcare: a scoping review of systematic reviews.

OBJECTIVES: Disinvestment from low value health technologies is growing globally. Diverse evidence gathering and assessment methods were used to implement disinvestment initiatives, however, less than half of the empirical studies report reduced use of the low-value services. This scoping review aimed to synthesize the information from available reviews on the concepts and purposes of disinvestment in healthcare, the approaches and methods used, the role of stakeholders and facilitators and barriers in its implementation. METHODS: This scoping review was guided by the Joanna Briggs Institute Manual for Evidence Synthesis and PRISMA statement for scoping review. Published reviews on disinvestment were identified from scientific databases including health technology assessment (HTA) Web sites using the terms "disinvestment," "health technology reassessment," and "healthcare." The data obtained was synthesized narratively to identify similarities and differences across the approaches based on the prespecified categories. RESULTS: Seventeen reviews were included with thirty-four initiatives identified across sixteen countries at various levels of implementation and responsible agencies for the activities. Two most used methods to facilitate disinvestment decisions are Programme Budgeting and Marginal Analysis (PBMA) and HTA. Stakeholder involvement is the most important aspect to be addressed, as it acts as both facilitator and barrier in disinvestment initiatives implementation. CONCLUSIONS: Disinvestment programs have been implemented at multilevel, involving multistakeholders and using multiple methods such as PBMA and HTA. However, there is a lack of clarity on the additional dimensions of technical analysis related to these tools. Further research could focus on technology optimization in healthcare as part of overall health technology management.

A voice to be heard: patient and public involvement in health technology assessment and clinical practice guidelines in Malaysia.

Patient and public involvement (PPI) in health technology assessment (HTA) is widely promoted to ensure that all health-related decisions are made after taking into consideration the viewpoints of important stakeholders. In Malaysia, patients or their representatives have been involved in the development of HTA and Clinical Practice Guidelines (CPG) since 2009 and their influences have been growing steadily over the years. This paper aimed to describe the journey, achievements, challenges, and future direction of the PPI throughout all stages of the development and implementation of HTA and CPG in Malaysia. Currently, in Malaysia, patients or their representatives are mainly involved during the initial development of HTA and CPG drafts as well as during the internal and external reviews. Additionally, they are also encouraged to be involved during the implementation of HTA and CPG recommendations. Although their involvement in this aspect has slowly increased over time, challenges remain in the form of limited representativeness of selected patients or carers, uncertainty on the level of patient involvement allowed during the HTA/CPG development processes, and limited health literacy, which affect their ability to contribute meaningfully throughout the processes. Continuous improvement in these processes is important as patients or their representatives play a pivotal role in ensuring transparency, accountability, and credibility throughout the HTA/CPG development and decision-making processes.

Cost-effectiveness of surgical interventions for the management of osteoarthritis: a systematic review of the literature.

BACKGROUND: The primary purpose of this study is to assess the existing evidence on the cost-effectiveness of surgical interventions for the management of knee and hip osteoarthritis by systematically reviewing published economic evaluation studies. METHODS: A systematic review was conducted for the period 2004 to 2016. Electronic databases were searched to identify both trial and model based economic evaluation studies that evaluated surgical interventions for knee and hip osteoarthritis. RESULTS: A total of 23 studies met the inclusion criteria and an assessment of these studies showed that total knee arthroplasty (TKA), and total hip arthroplasty (THA) showed evidence of cost-effectiveness and improvement in quality of life of the patients when compared to non-operative and non-surgical procedures. On the other hand, even though delaying TKA and THA may lead to some cost savings in the short-run, the results from the study showed that this was not a cost-effective option. CONCLUSIONS: TKA and THA are cost-effective and should be recommended for the management of patients with end stage/severe knee and hip OA. However, there needs to be additional studies to assess the cost-effectiveness of other surgical interventions in order for definite conclusions to be reached.

Genetic-Guided Pharmacotherapy for Coronary Artery Disease: A Systematic and Critical Review of Economic Evaluations.

BACKGROUND: Genetic-guided pharmacotherapy (PGx) is not recommended in clinical guidelines for coronary artery disease (CAD). We aimed to examine the extent and quality of evidence from economic evaluations of PGx in CAD and to identify variables influential in changing conclusions on cost-effectiveness. METHODS AND RESULTS: From systematic searches across 6 databases, 2 independent reviewers screened, included, and rated the methodological quality of economic evaluations of PGx testing to guide pharmacotherapy for patients with CAD. Of 35 economic evaluations included, most were model-based cost-utility analyses alone, or alongside cost-effectiveness analyses of PGx testing to stratify patients into antiplatelets (25/35), statins (2/35), pain killers (1/35), or angiotensin-converting enzyme inhibitors (1/35) to predict CAD risk (8/35) or to determine the coumadin doses (1/35). To stratify patients into antiplatelets (96/151 comparisons with complete findings of PGx versus non-PGx), PGx was more effective and more costly than non-PGx clopidogrel (28/43) but less costly than non-PGx prasugrel (10/15) and less costly and less effective than non-PGx ticagrelor (22/25). To predict CAD risk (51/151 comparisons), PGx using genetic risk scores was more effective and less costly than clinical risk score (13/17) but more costly than no risk score (16/19) or no treatment (9/9). The remaining comparisons were too few to observe any trend. Mortality risk was the most common variable (47/294) changing conclusions. CONCLUSIONS: Economic evaluations to date found PGx to stratify patients with CAD into antiplatelets or to predict CAD risk to be cost-effective, but findings varied based on the non-PGx comparators, underscoring the importance of considering local practice in deciding whether to adopt PGx.

Health financing challenges in Southeast Asian countries for universal health coverage: a systematic review.

BACKGROUND: Universal Health Coverage (UHC) has received much attention and many countries are striving to achieve it. The Southeast Asian region, in particular, comprises many developing countries with limited resources, exacerbating challenges around attaining UHC. This paper aims to specifically explore the health financing challenges these countries face in achieving UHC via a systematic review approach and formulate recommendations that will be useful for policymakers. METHODS: The systematic review followed the guidelines as recommended by PRISMA. The narrative synthesis approach was used for data synthesis, followed by identifying common themes. RESULTS: The initial search returned 160 articles, and 32 articles were included after the screening process. The identified challenges in health financing towards achieving UHC in the Southeast Asian region are categorised into six main themes, namely (1) Unsustainability of revenue-raising methods, (2) Fragmented health insurance schemes, (3) Incongruity between insurance benefits and people's needs, (4) Political and legislative indifference, (5) Intractable and rapidly rising healthcare cost, (6) Morally reprehensible behaviours. CONCLUSIONS: The challenges identified are diverse and therefore require a multifaceted approach. Regional collaborative efforts between countries will play an essential role in the progress towards UHC and in narrowing the inequity gap. At the national level, individual countries must work towards sustainable health financing strategies by leveraging innovative digital technologies and constantly adapting to dynamic health trends. REGISTRATION: This study is registered with PROSPERO, under registration number CRD42022336624.

How Least Developed to Lower-Middle Income Countries Use Health Technology Assessment: A Scoping Review.

Health Technology Assessment (HTA) is a multidisciplinary tool to inform healthcare decision-making. HTA has been implemented in high-income countries (HIC) for several decades but has only recently seen a growing investment in low- and middle-income countries. A scoping review was undertaken to define and compare the role of HTA in least developed and lower middle-income countries (LLMIC). MEDLINE and EMBASE databases were searched from January 2015 to August 2021. A matrix comprising categories on HTA objectives, methods, geographies, and partnerships was used for data extraction and synthesis to present our findings. The review identified 50 relevant articles. The matrix was populated and sub-divided into further categories as appropriate. We highlight topical aspects of HTA, including initiatives to overcome well-documented challenges around data and capacity development, and identify gaps in the research for consideration. Those areas we found to be under-studied or under-utilized included disinvestment, early HTA/implementation, system-level interventions, and cross-sectoral partnerships. We consider broad practical implications for decision-makers and researchers aiming to achieve greater interconnectedness between HTA and health systems and generate recommendations that LLMIC can use for HTA implementation. Whilst HIC may have led the way, LLMIC are increasingly beginning to develop HTA processes to assist in their healthcare decision-making. This review provides a forward-looking model that LLMIC can point to as a reference for their own implementation. We hope this can be seen as timely and useful contributions to optimize the impact of HTA in an era of investment and expansion and to encourage debate and implementation.

From Evidence to Policy: Economic Evaluations of Healthcare in Malaysia: A Systematic Review.

OBJECTIVE: To identify and describe the various economic evaluation studies in Malaysia and to determine the range of incremental cost-effectiveness ratios (ICERs) as reported in these studies. METHODS: A comprehensive search of the scientific electronic databases was conducted (Medline, EBM Reviews, Embase, and hand search) to identify all published economic evaluation studies related to Malaysian healthcare. Two researchers assessed the quality of selected studies using the Critical Appraisal Skills Programme (CASP) checklist and Quality of Health Economic Studies instrument. The assessment was also reviewed by expert members of the Technical Advisory Committee of Health Technology Economic Evaluations (TACHTEE). RESULTS: A total of 64 full-text articles were assessed for eligibility and included in this systematic review. Thirty studies were partial economic evaluations; the full economic evaluations included 17 cost-effectiveness analyses and 17 cost-utility analyses. From all the reported ICERs, the majority (68%) were categorized as highly cost-effective (ICER of less than 1 gross domestic product (GDP) per capita per quality-adjusted life-years or disability-adjusted life-years gained). CONCLUSION: This review identifies information gaps and loopholes in health economics research in Malaysia. Additionally, this study provides the information that the majority of published interventions in Malaysia fell within the cost-effectiveness threshold of 1 GDP per capita per quality-adjusted life-years or disability-adjusted life-years gained.