potential for disinvestment in procedures of low health gain in scotland

Priorities in Health Care Conference, November 2004

Potential for disinvestment Potential for disinvestment in procedures of low health gain in procedures of low health gain

in Scotlandin Scotland

Dr Sheila N Scott Director of Public HealthWestern Isles NHS Board

37 South Beach StreetStornoway, Isle of Lewis,

HS1 2BB, Scotland, [email protected]


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CONTENTS

• Objectives

• Methodology/Project design

• Results to date

• Where next


OBJECTIVES

To undertake a stocktake across Scotland of Scottish Health

Boards about any work to stop/curtail interventions of low or

no health gain

If so: what and by whom?

What initiated such work - guidelines, HTA guidance, audit, Quality Improvement Scotland etc.?

•Quantify nationally what the number of procedures might be

•Calculate the opportunity cost/disinvestment potential

•This project is on behalf of Scottish Directors of Public Health


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BACKGROUND

•Each Health Board has a Director of Public Health and denominator population from (25,000 - 1.1 million)

•Hospital activity for past 30 years

Western Isles

Highland

Orkney

Shetland

Grampian

15 Health Boards


METHODOLOGYLiterature review in November ‘02 by Ann Lees, (Health Economist).

Clinical Evidence

A compendium of the best available research findings on common and important

clinical questions, which is updated and expanded every six months. Published jointly

by the BMJ Publishing Group and the American College of Physicians. Sample pages

from the website http://www.bmjpg.com/evid99/index.html

Evidence Based Medicine

Bi-monthly, to survey at least 70 international medical journals to identify the key

research papers that are scientifically valid and relevant to practice. These articles are

selected according to scientific criteria and only those papers with direct message for

practice are included. Covering internal medicine, general surgery, paediatrics,

obstetrics, gynaecology, psychiatry, general practice, anaesthesiology and

ophthalmology. http://www.bmjpg.com/data/ebm.htm


ANALYSIS OF LITERATURE REVIEW

Count of Type of Intervention

Type of Intervention

Likely to be ineffective or

harmful

Trade off between

benefits and harms

Unknown effectiveness

Unlikely to be beneficial Total

Diagnostic Test 0 0 3 5 8Drug / Therapy / Treatment 29 49 235 44 357Surgery 2 4 32 8 46Education/Lifestyle / Prevention / Screening 0 0 20 2 22Hospital Care / Model of Care / Not Specified 0 0 9 9 18Grand Total 31 53 299 68 451

Evidence - Category

Nb. “unknown” effectiveness does not = no effectiveness

7Priorities in Health Care Conference, November 2004

METHODOLOGY

• Questionnaire for each Health Board designed and piloted in 2 Health Boards - one large one small.

• Information Services Division, National Services Scotland approached re analysis of some sentinel procedures chosen from literature review, as a pilot.


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RESULTS

Structured questionnaire pilot

FEEDBACK

too much work required to make stocktake comprehensive

no central repository/responsibility for such work

confusion over disinvestment rationale - efficiency (access and

frequency) vs low health gain

people too busy completing forms for other purposes

but happy with principle if supported


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Health Technology Section of Quality Improvement Scotland re ‘sentinel’ conditions and progress on full HTAs’

•Tonsillectomy and grommets (ENT)

•Dilatation & Curettage (Gynaecological)

•Varicose Veins (Surgical)

•Grommets (ENT)

But not reporting for some years.


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NHS Board ofresidence

Tonsillectomies Grommetoperation

D&C VaricoseVeins

Scotland 86 57 92 941 100 50 247 1012 106 53 73 1153 78 91 180 724 110 111 63 935 61 37 93 956 59 59 150 937 89 78 42 1188 97 40 45 759 89 68 32 13210 98 50 78 8911 69 72 113 7412 109 83 150 17613 151 155 105 13314 70 40 56 10015 149 42 272 149Minimum rate 59 37 32 72

Results from ISD

Rate per 100,000 population of ‘sentinel conditions’

Variation x2 - x9 (D&Cs) between each Health Board


Tonsillectomies Grommets D&C Varicose Veins1998/99 7706 5150 7135 76282000/01 4469 3509 5914 57892003/04 4372 2908 4656 4751

Secular trends downwards:

Scotland

but not uniform.

Total number of ‘sentinel’ procedures was 17,000 in 2003/04


NHS Board ofresidence

Tonsillectomies Grommetoperations on

ear

D&C VaricoseVeins

Totals

Scotland 1370 1040 3035 1108 65531 168 54 898 120 12402 173 57 144 159 5333 20 59 160 0 2394 75 110 46 31 2615 4 0 215 79 2996 0 61 329 59 4497 157 216 50 239 6628 330 26 115 30 5019 62 65 0 124 25110 214 72 253 94 63211 72 272 628 13 98512 10 9 23 20 6113 20 26 16 13 7514 43 13 94 107 25615 24 1 63 20 108

Clinicians will say “Some procedures will always be necessary”

Number of procedures that could be avoided if the lowest rate was applied to all NHS Boards for ‘sentinel’ conditions. (total in Scotland in 2003/4=16,687)


Are there significant correlations and differences between the rates in different Health Boards for different procedures?

1. Spearman’s product moment correlation - There is a significant correlation between the rates of tonsillectomy and rates of Varicose veins operations carried out by HB’s (r=.587,p=0.022)

2. ANOVA (1 way) Looked for significant variation in the rates between different HB types (RR, Mixed and Urban) - Results show that there is significant differences in rates for tonsillectomies (p=0.002) and varicose veins (p=0.001) between different HB types.

3.Post hoc Tukey test shows that there are no significant differences between Urban and Mixed but both are significantly different from Remote and Rural


Possible explanations?

• HB definitions (a mixture of density and no conurbation > 20,000)

• Capacity/referral issues• Data population based not hospital based• Weighting by 1 or 2 clinicians• Other• Effect small in terms of numbers nationally


CONCLUSIONS• Great potential to ‘save’ 6,500 operations from 4 ‘sentinel’

conditions, perhaps more

• Health Boards and QIS, Scottish Medicines Consortium and others providing resources to promulgate/evaluate new technologies

• Publication bias towards newer procedures/technologies

• Nobody appears to have responsibility for stopping things that do not work or which may harm patients (reducing demand)

• Dedicated resource to facilitate this required in Scotland


What next??• DsPH to discuss sentinel procedures with

MDs after October presentation to MD’s)?• Role of Royal Colleges and others?• Who else should be involved and how?• Resource required to update literature and

look at potential in other areas• Other issues???• Potential for International collaboration

potential for disinvestment in procedures of low health gain in scotland

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