Disinvestment in cancer care: a survey investigating European countries’ opinions and views

Disinvestment in cancer care: a survey investigating European countries’ opinions and views Abstract Background The current economic context calls for rationalizing health resources that can be pursued through disinvestment from low value health technologies to invest in the best performing ones, ensuring high healthcare quality. Oncology is a field where, because of high costs of health technologies and rapid innovation, disinvestment is crucial. Methods On this basis, the research team investigated through a survey, based on a questionnaire, opinions and views of representatives of European countries about disinvestment, in terms of fields of application, potential advocates and barriers, specifically focusing on cancer care. Results A total of 17 questionnaires were filled in (response rate: 32.1%). The survey showed disinvestment is applied in several countries as a tool for containing health care expenditures and identifying obsolete technologies/ineffective interventions. Clinicians’ resistance to change and industries’ opposition are recognized as the most important barriers to the implementation of disinvestment policies. Potential targets of disinvestment in cancer are seen in diagnostic and therapeutic areas. Conclusion Despite the agreement on fields of waste and of disinvestment policies, operational methods to put disinvestment in place are lacking. Since they should rely on an inclusive assessment of the technology, Health Technology Assessment may represent a good approach. Introduction In an era of a growing economic pressure, health systems all over the world are tackling, on one hand, an uncontrolled increase in demand for health services—mainly due to epidemiological and demographic trends (population aging and expanding incidence of chronic diseases)—on the other, the advent of more innovative and expensive technologies. This makes the protection of public welfare unsustainable, both in the short and the medium-long term. Therefore, the economic and financial sustainability of health systems and the optimal allocation of resources have become central issues in exercising health protection.1,2 Due to the growing concern of policy makers about the increase in health expenditure, more attention has been paid to economic efficiency issues even in health systems based on universalism principles. If in the past introducing a new technology imposed the main question of its effectiveness, now-a-days the assessment of its sustainability by the system cannot be neglected.3 In this context, the introduction, dissemination and implementation of evidence-based tools, aimed to the rationalization of the available resources, according to logic of social equity and economic sustainability, seems essential in the perspective of allocative efficiency. Therefore, there is a growing interest by policy and decision makers towards approaches to optimize use of available health technologies, also reducing their use or disinvesting from those that offer little or no benefit.1,2,4 During the last decade, the importance of disinvestment has been recognized by several countries. In September 2006, the Department of Health of the United Kingdom announced the new mandate for the National Institute for Health and Clinical Excellence (NICE) to support the National Health Service (NHS) in identifying non-effective technologies. To this purpose, NICE provided tools and recommendations to guide the process of health technology disinvestment.5–7 Progressively, other countries have payed specific attention to disinvestment, including Australia (with the first publications on the topic in 2007),8,9 the Swedish Council on Technology Assessment in Health Care (SBU), the West Scotland NHS and the Canadian Agency for Drugs and Technologies in Health (CADTH). In Spain, after the release- on 15 September 2006–of the Royal Decree 1030 on disinvestment, a project entitled ‘The identification, prioritization and evaluation of potentially obsolete health technologies’ was carried out by two regional HTA agencies.5 In 2010, a specific Interest Sub-Group on Disinvestment and Early Awareness was established within the HTA International Society (HTAi). It is aimed to be a key international center in sharing knowledge and expertise on methods for prioritization and evaluation of obsolete or low added value technologies and on disinvestment implementation in health systems.10 According to Elshaug AG et al., disinvestment consists of ‘withdrawing health resources from any existing health care practices, procedures, technologies or pharmaceuticals that are deemed to deliver little or no health gain for their cost and thus are not efficient health resource allocations’.8 The current economic context requires a re-organization and a re-allocation of resources, that can be pursued through the principle of ‘disinvest to re-invest’. However, disinvestment is not such a simple and straightforward process and makes it necessary to choose, based on evidence, the areas of intervention to be disinvested in order to re-invest.11,12 Oncology is a field where, because of high costs of health technologies and rapid innovation, disinvestment from clinical interventions with lower performance is crucial to invest in the best performing ones and ensure high levels of healthcare quality.13 Given the increased incidence and prevalence of oncological diseases and the availability of new therapeutic tools, the question of how to ensure access to new technologies and economic sustainability must be addressed.14,15 The aim of this study has been to investigate European countries’ opinions and views about disinvestment, in terms of fields of application, potential advocates and barriers specifically focusing on cancer care. Methods Study design and population A survey was conducted to address opinions and views of representatives of European countries on the topic of disinvestment, particularly regarding to its application in cancer care. The survey was part of a broader European project on cancer control and was carried out through a questionnaire sent to 53 representatives on 27 July 27 2015. Representatives were selected by the Italian Ministry of Health (MoH) among people belonging to MoH and/or HTA agencies and/or national institutions working in the field of oncology of each country and were addressed with two reminders. Questionnaire The questionnaire was first developed by a group of four experts in HTA and Health Management and was assessed in terms of content validity through a Delphi process involving five experts from the same fields and from the Italian MoH. The questionnaire consisted of two sections, one on disinvestment and the other on disinvestment in cancer care. Under each section, different topics were addressed. The first part tackled disinvestment policies put in place at the national level; use, objectives and advocates of disinvestment initiatives; barriers to the development and the adoption of disinvestment initiatives. The part on disinvestment in cancer care dealt with: waste of resources; areas and drivers of waste; need, targets, reasons for disinvestment policies; advocates of disinvestment policies. Each topic enclosed different statements evaluated through a Likert scale (strongly disagree; disagree; do not know; agree; strongly agree). Statistical analysis A descriptive analysis was carried out through absolute and relative frequencies. Tables were used to report results. Results A total of 17 questionnaires were filled in (response rate: 32.1%). All the respondents, except one, provided information on the country and the institution of origin. Respondents’ countries and institutions were as follows: Austria: Ministry of Health. Austria: Ludwig Boltzmann Institute of HTA. Basque Country: Osteba, Basque Office for HTA. Belgium: NIHDI (National Institute for Health and Disability Insurance). Croatia: Croatian Institute of Public Health. Cyprus: Ministry of Health. Germany: German Institute for Medical Documentation and Information. Hungary: National Institute of Oncology. Ireland: Department of Health. Italy: Ministry of Health. Lithuania: National Cancer Institute. Netherlands: Zorginstituut Nederland. Norway: Norwegian Directorate of Health. Poland: Ministry of Health. Spain: Ministry of Health (second round). Switzerland: Federal Office of Public Health FOPH. Sixteen out of 17 respondents reported their position: 8 (50%) were policy makers, 1 (6.3%) was a healthcare manager and 1 (6.3%) was a physician whereas the remaining 6 (37.5%) were other professionals. The results of the survey are reported separately for the first and the second part of the questionnaire. Disinvestment in general Nine (52.9%) respondents declared a disinvestment policy is in place in their country. Eleven respondents (around 65%) considered disinvestment initiatives useful to reduce unwarranted variations in clinical practice and allow a re-allocation of resources from low-value to high-value services/programmes. Twelve respondents (more than 70%) foresaw a role in improving overall quality of care reducing exposure to unsafe and ineffective interventions. Large agreement was reached on the utility of disinvestment activities for containing health care expenditures. Sixteen respondents (more than 90%) agreed or strongly agreed that disinvestment initiatives should be aimed at identifying obsolete technologies or interventions whose ineffectiveness has been clearly demonstrated. Fourteen (more than 80%) agreed or strongly agreed that disinvestment initiatives should be aimed at identifying low-value interventions whereas twelve (more than 70%) recognized a role in identifying interventions with uncertain or questionable clinical value and used inappropriately (table 1). Table 1 Use and objectives of disinvestment initiatives Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Table 1 Use and objectives of disinvestment initiatives Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Respondents agreed or strongly agreed on the involvement of hospital managers, policy makers, researchers, clinicians, patients and their families, industries and citizens, respectively, in 13 out of 15 (86.7%), 13 out of 15 (86.7%), 10 out of 16 (62.6%), 9 out of 16 (56.3%), 4 out of 15 (26.7%), 4 out of 15 (26.7%) and 2 out of 14 (14.3%) cases. Twelve respondents (around 70%) recognized clinicians’ resistance to change and industries’ opposition as barriers to the implementation of disinvestment policies. More than half of respondents considered the following factors as barriers: lack of reliable and easily available information on current clinical practice and of scientific information on safety, effectiveness and costs of health care interventions and weak political willingness to undertake disinvestment initiatives. On the contrary, citizens’ and patients’ opposition was seen as a concern by less than half of respondents (table 2). Table 2 Barriers to disinvestment Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Table 2 Barriers to disinvestment Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Disinvestment in cancer care Regarding disinvestment in cancer care two areas were analyzed, one about waste and another on policies. The synthesis of results is reported separately for the two sections. Waste Twelve out of 15 respondents (80%) providing their view affirmed that, in cancer care, the amount of resources wasted is significant. As far as the areas of waste, 11 out of 14 (78.6%) and 13 out of 14 (92.8%) respondents identified, respectively, the diagnostic and therapeutic activities at secondary care level (table 3). On the contrary, 8 out of 14 (57.1%) and 9 out of 14 (64.3%) respondents disagreed that tertiary care and prevention are areas at risk of waste (table 3). Table 3 Areas and drivers of waste Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Table 3 Areas and drivers of waste Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Twelve out of 16 respondents (75%) agreed inadequate health professionals’ education and training, physicians’ excessive reliance on supposedly innovative new technologies and defensive medicine may play a substantial role in determining waste (table 3). Furthermore, 13 out of 16 (more than 80%) considered bad information of patients and families on the value of diagnostic and therapeutic interventions and industries pressure as influent (table 3). Disinvestment policies Thirteen respondents (76.5%) believed disinvestment policies in oncology are necessary. Nonetheless, three respondents (17.6%) were not able to give their opinion, whereas one (5.9%) did not agree with the need for disinvestment policies in this field. Disinvestment policies were considered necessary, particularly to (in a descending order for importance): reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures, contain health care expenditures, obtain resources to make care more accessible to many patients, sustain valuable innovations in clinical practice, because there are still low-value interventions and too much variation in daily clinical practice (table 4). Table 4 Reasons and target of disinvestment policies Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) Table 4 Reasons and target of disinvestment policies Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) In respect to the target of disinvestment policies, 11 out of 11 respondents (100%) identified drugs and diagnostic procedures as fields of disinvestment. Seven out of 11 (more than 60%) listed health services organizational models and screening. The situation was mixed regarding surgical treatments and palliative care (table 4). Disinvestment policies are seen to be supported by hospital managers first (11 out of 12 respondents, namely more than 90%, agreed on that). Eight out of 12 (75%) considered policy makers and researchers important. Half or more of respondents did not have a position with respect to the involvement of citizens and patients and families while 7 out of 12 (around 60%) disagreed on the involvement of industry. Finally, the role of clinicians was more debated. Discussion This survey showed disinvestment is applied in several countries as a tool for containing health care expenditures and identifying obsolete technologies or ineffective interventions. Alongside it, clinicians’ resistance to change and industries’ opposition are recognized as the most important barriers to the implementation of disinvestment policies. A first aspect arising from the survey that is worth considering is the extent of application of disinvestment policies across Europe. Even though more than 50% of responders reported that a disinvestment policy was in place in their countries, there is the need to get a consensus on the meaning of disinvestment to have a clear picture of the situation and make fair comparisons. If the goals of disinvestment are clear, the definition of a disinvestment policy, its framework and methods are less shared and standardized. According to the well-known definition of Elshaug et al.,3 disinvestment is ‘the process of (partially or completely) withdrawing health resources’ from low-value health technologies that represent an inefficient investment. Disinvestment is about resource re-allocation, not merely the promotion of the appropriate use of a health technology. In this respect, it can be misleading to consider disinvestment policies as aimed at cost-containing. The final goal is to identify and to disinvest from the so-called ‘obsolete’ technologies, namely those superseded by other technologies or demonstrated to be ineffective or harmful.16 We cannot conclude to what extent disinvestment policies meet these goals in the different countries, because it is well known that, in some contexts, disinvestment is attributed a negative connotation, namely ‘financially-motivated denial of care’.17 Budget concerns are a public health issue, and healthcare systems worldwide are facing the issue of wasteful health spending. About one-fifth of health expenditure in OECD countries makes a minimal or no contribution to people’s health improvement.18 According to Berwick and Hackbarth, one of the six main categories of health waste is represented by over-treatment.19 In fact, the overuse of a wide spectrum of health services as a source of waste and harmful to both patients and health systems, has been well documented.20 In particular, ordinary admissions, diagnostic imaging and drugs have been identified as the most overused services and, therefore, the main drivers of waste in healthcare.21 Our survey showed waste is a big concern also in cancer care. Waste is mostly seen in diagnostic and therapeutic areas, and the following play an important role: inadequate health professionals’ education and training; physicians’ excessive reliance on innovative new technologies; defensive medicine and bad information of patients. It should be considered that oncology is an area of fast increasing costs. The last can be attributable to the increased burden of oncological diseases and to the availability of innovative, more expensive therapies, the more aggressive care provided by physicians, the patients’ survival gains and, consequently, the increased treatment times.13 There is not much evidence on comparisons of cancer care costs across health systems that are challenging.22 Cancer-related healthcare costs across the European Union (EU) have been estimated by Luengo-Fernandez et al. to amount to €51.0 billion (4% of total EU healthcare expenditure), with inpatient care costs and drug expenditure accounting for 56% and 27% of cancer-related healthcare costs, respectively.23 In light of all abovementioned considerations, policies on disinvestment, in particular on cancer drugs, diagnostics and hospitalizations, should be fostered. But how to translate it into practice? The evidence offers two valuable approaches. The first one is represented by the Clinical Guidelines Program started in the United Kingdom, in 2001, by the NICE. This program, aimed to the development of guidelines focused on the improvement of standard of care, gives the opportunity to discuss not only new investments but also disinvestments in healthcare. During the guideline production process, indeed, the discontinuation or the optimization of practices/procedures of limited use or applied in an inefficient way are often discussed by the Guideline Development Group and some of the resulting suggestions are integrated in the ‘Do not do’ list available on the NICE Website. Among the clinical guidelines produced by the program, there are also disinvestment recommendations, i.e. on bladder cancer and advanced breast cancer.24 The second applies the league-table approach and proposes a framework to support the decision making of the NHS England’s Cancer Drugs Fund (CDF) by determining suitable cost-effectiveness thresholds. The authors concluded the adoption of this framework for the prioritization activity of the CDF would determine disinvestment from cost-ineffective drugs refundable by CDF.25 Furthermore, a recent review makes an overview of the implemented disinvestment program or structured experience to identify, prioritize and assess obsolete technologies. The paper shows most programs are implemented outside Europe, namely Australia and Canada.26 There are several papers addressing unnecessary, i.e. overused, interventions in cancer care.27–29 They have highlighted resulting health wastes and the importance of nationwide recommendations on the assessment of health technologies in light of disinvestment. The agreement on fields of waste and disinvestment policies sheds lights on how to pursue resource re-allocation in cancer care. Nonetheless, operational methods to put disinvestment in place are lacking, even though the scientific community is recognizing Health Technology Assessment (HTA) as a suitable approach,2 first of all because it allows the evaluation of several criteria12 at the same time and, second, because it employs a systematic approach. Third, HTA is a policy-oriented process born and used to support decision-making and it has been shown that the presence of an HTA agency is associated to the probability of having disinvestment programs in the country.26 Nevertheless, decision-making processes are undermined by several barriers. Generally, they entail lack of resources and data/evidence, but also clinicians’ resistance to change30 that has been identified as one of the major barriers to disinvestment policies in our survey. Clinicians’ resistance to change might have a nationwide, as well as a local, dimension. In the latter, political, social and clinical challenges may play an important role.31 Our survey also showed concerns about industries’ opposition whose role may be related to the lack of central commitment and to difficulties in collaborations, which have been described by the scientific evidence as ideological barriers to disinvestment.17 The clinicians’ resistance to change and industries’ opposition may be addressed by the adoption and the implementation of multi-stakeholders approaches such as the HTA. Because of the latter characteristic, its multi-disciplinary and evidence-based approach, HTA should be considered a pillar for investing and for disinvesting in health. Our work has some limits. First, the survey was performed on an opportunistic sample of representatives from European countries with a low response rate. This aspect might limit the transferability of results to the whole of Europe. Second, the questionnaire used to carry out the survey was not validated, limiting the generalizability of results and it only assessed personal knowledge and attitudes of responders, with no check on institutional documents. Nevertheless, to the best of our knowledge, our work is the first to address views and opinions on disinvestment across Europe and responders came back from all the European regions, allowing to get a first overview of the perspectives on this challenging topic. Acknowledgements The project is a part of the activities funded under the Italian National Centre for Disease Prevention and Control to support the Ministry of Health in co-ordinating and implementing the workpackage 5 of the European Joint Action CanCon. Funding The project is a part of the activities funded under the Italian National Centre for Disease Prevention and Control to support the Ministry of Health in co-ordinating and implementing the workpackage 5 of the European Joint Action CanCon. Conflicts of interest: None declared Key points The economic and financial sustainability of health systems and the optimal allocation of resources are central public health issues and there is a growing interest towards approaches to optimize the use of health technologies, while disinvesting from those of little or no value. Because of high costs of health technologies and rapid innovation, disinvestment from clinical interventions with lower performance is crucial in Oncology to ensure healthcare quality. Disinvestment is applied in several countries to contain health care expenditures and identify obsolete technologies/ineffective interventions. Clinicians’ resistance to change and industries’ opposition are recognized as the most important barriers to the implementation of disinvestment policies, while potential disinvestment targets in cancer are seen in diagnostic and therapeutic areas. Because of its multi-disciplinary, multi-stakeholders and evidence-based approach, HTA should be considered a pillar for investing and disinvesting in health. References 1 Donaldson C , Bate A , Mitton C , et al. Rational disinvestment . QJM: Monthly J Assoc Phys 2010 ; 103 : 801 – 7 . 2 Henshall C , Schuller T , Mardhani-Bayne L . Using health technology assessment to support optimal use of technologies in current practice: the challenge of ‘ disinvestment’. Int J Technol Assess Health Care 2012 ; 28 : 203 – 10 . Google Scholar CrossRef Search ADS PubMed 3 Elshaug AG , Hiller JE , Moss JR . Exploring policy-makers’ perspectives on disinvestment from ineffective healthcare practices . Int J Technol Assess Health Care 2008 ; 24 : 1 – 9 . Google Scholar CrossRef Search ADS PubMed 4 Prasad V , Cifu A , Ioannidis JP . Reversals of established medical practices: evidence to abandon ship . JAMA 2012 ; 307 : 37 – 8 . Google Scholar CrossRef Search ADS PubMed 5 Ibargoyen-Roteta N , Gutiérrez-Ibarluzea I , Asua J . Guiding the process of health technology disinvestment . Health Policy 2010 ; 98 : 218 – 26 . Google Scholar CrossRef Search ADS PubMed 6 Pearson S , Littlejohns P . Reallocating resources: how should the National Institute for Health and Clinical Excellence guide disinvestment efforts in the National Health Service? J Health Serv Res Policy 2007 ; 12 : 160 – 5 . Google Scholar CrossRef Search ADS PubMed 7 NICE . Improving Health and Social Care Through Evidence-Based Guidance. Available at: https://www.nice.org.uk (24 July 2017, date last accessed). 8 Elshaug AG , Hiller JE , Tunis SR , Moss JR . Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices . Aust New Zealand Health Policy 2007 ; 4 : 23 . Google Scholar CrossRef Search ADS PubMed 9 Department of Human Services . Future Directions for Health Technology Uptake, Diffusion and Disinvestment in Victorian Public Health Services . Victoria, Australia : Department of Human Services , 2007 . 10 Health Technology Assessment International . HTAi Interest Sub-Group on HTAi Interest Group on Disinvestment and Early Awareness. Available at: http://www.htai.org/index.php? id=540 (24 July 2017, date last accessed). 11 MacKean G , Noseworthy T , Elshaug AG , et al. Health technology reassessment: the art of the possible . Int J Technol Assess Health Care 2013 ; 29 : 418 – 23 . Google Scholar CrossRef Search ADS PubMed 12 Grilli R , Espin J , Florindi F , De Lorenzo F . Policy Paper on Enhancing the Value of Cancer Care Through a More Appropriate Use of Healthcare Interventions. Cancer Control Joint Action–Policy Paper. Available at: https://cancercontrol.eu/archived/uploads/PolicyPapers27032017/Policy_Paper_3_Enhancing.pdf (24 July 2017, date last accessed). 13 Eagle D . The cost of cancer care: part I . Oncology (Williston Park) 2012 ; 26 : 918 – 21, 924 . Google Scholar PubMed 14 Rotily M , Roze S . What is the impact of disease prevalence upon health technology assessment? Best Pract Res Clin Gastroenterol 2013 ; 27 : 853 – 65 . Google Scholar CrossRef Search ADS PubMed 15 Chabot I , Rocchi A . Oncology drug health technology assessment recommendations: canadian versus UK experiences . Clinicoecon Outcomes Res 2014 ; 6 : 357 – 67 . Google Scholar CrossRef Search ADS PubMed 16 Goodman CS . HTA 101: Introduction to Health Technology Assessment . Bethesda, MD : National Library of Medicine (US) . Available at: https://www.nlm.nih.gov/nichsr/hta101/HTA_101_FINAL_7-23-14.pdf (24 July 2017, date last accessed). 17 Rooshenas L , Owen-Smith A , Hollingworth W , et al. ‘I won't call it rationing…’: an ethnographic study of healthcare disinvestment in theory and practice . Soc Sci Med 2015 ; 128 : 273 – 81 . Google Scholar CrossRef Search ADS PubMed 18 OECD . Tackling Wasteful Spending on Health . Paris : OECD Publishing , 2017 . 19 Berwick DM , Hackbarth AD . Eliminating waste in US health care . JAMA 2012 ; 307 : 1513 – 6 . Google Scholar CrossRef Search ADS PubMed 20 Brownlee S , Chalkidou K , Doust J , et al. Evidence for overuse of medical services around the world . Lancet 2017 ; 390 : 156 – 68 . Google Scholar CrossRef Search ADS PubMed 21 Fondazione GIMBE . 2° Rapporto GIMBE Sulla Sostenibilità Del Servizio Sanitario Nazionale (2° GIMBE Report on the Sustainability of the National Health Service) . Bologna : Fondazione GIMBE. Availabale at : www.rapportogimbe.it (24 July 2017, date last accessed). 22 Lipscomb J , Yabroff KR , Hornbrook MC , et al. Comparing cancer care, outcomes, and costs across health systems: charting the course . J Natl Cancer Inst Monogr 2013 ; 2013 : 124 – 30 . Google Scholar CrossRef Search ADS PubMed 23 Luengo-Fernandez R , Leal J , Gray A , Sullivan R . Economic burden of cancer across the European Union: a population-based cost analysis . Lancet Oncol 2013 ; 14 : 1165 – 74 . Google Scholar CrossRef Search ADS PubMed 24 Drummond M . Clinical guidelines: a NICE way to introduce cost-effectiveness considerations? Value Health 2016 ; 19 : 525 – 30 . Google Scholar CrossRef Search ADS PubMed 25 Leigh S , Granby PA . Tale of two thresholds: a framework for prioritization within the cancer drugs fund . Value Health 2016 ; 19 : 567 – 76 . Google Scholar CrossRef Search ADS PubMed 26 Orso M , de Waure C , Abraha I , et al. Health technology disinvestment worldwide: overview of programs and possible determinants . Int J Technol Assess Health Care 2017 ; 33 : 239 – 50 . Google Scholar CrossRef Search ADS PubMed 27 Spence MT , Woodman C , Collins S , et al. Cervical smears–an opportunity for disinvestment? Br J Gen Pract 1996 ; 46 : 537 – 8 . Google Scholar PubMed 28 Bending MW , Trueman P , Lowson KV , et al. Estimating the direct costs of bowel cancer services provided by the National Health Service in England . Int J Technol Assess Health Care 2010 ; 26 : 362 – 9 . Google Scholar CrossRef Search ADS PubMed 29 O’Mahony JF , Normand C . HIQA’s CEA of breast screening: pragmatic policy recommendations are welcome, but ACERs reported as ICERs are not . Value Health 2015 ; 18 : 941 – 5 . Google Scholar CrossRef Search ADS PubMed 30 Harris C , Allen K , Waller C , Brooke V . Sustainability in health care by allocating resources effectively (SHARE) 3: examining how resource allocation decisions are made, implemented and evaluated in a local healthcare setting . BMC Health Serv Res 2017 ; 17 : 340 . Google Scholar CrossRef Search ADS PubMed 31 Polisena J , Clifford T , Elshaug AG , et al. Case studies that illustrate disinvestment and resource allocation decision-making processes in health care: a systematic review . Int J Technol Assess Health Care 2013 ; 29 : 174 – 84 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Disinvestment in cancer care: a survey investigating European countries’ opinions and views

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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1101-1262
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1464-360X
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10.1093/eurpub/cky033
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Abstract

Abstract Background The current economic context calls for rationalizing health resources that can be pursued through disinvestment from low value health technologies to invest in the best performing ones, ensuring high healthcare quality. Oncology is a field where, because of high costs of health technologies and rapid innovation, disinvestment is crucial. Methods On this basis, the research team investigated through a survey, based on a questionnaire, opinions and views of representatives of European countries about disinvestment, in terms of fields of application, potential advocates and barriers, specifically focusing on cancer care. Results A total of 17 questionnaires were filled in (response rate: 32.1%). The survey showed disinvestment is applied in several countries as a tool for containing health care expenditures and identifying obsolete technologies/ineffective interventions. Clinicians’ resistance to change and industries’ opposition are recognized as the most important barriers to the implementation of disinvestment policies. Potential targets of disinvestment in cancer are seen in diagnostic and therapeutic areas. Conclusion Despite the agreement on fields of waste and of disinvestment policies, operational methods to put disinvestment in place are lacking. Since they should rely on an inclusive assessment of the technology, Health Technology Assessment may represent a good approach. Introduction In an era of a growing economic pressure, health systems all over the world are tackling, on one hand, an uncontrolled increase in demand for health services—mainly due to epidemiological and demographic trends (population aging and expanding incidence of chronic diseases)—on the other, the advent of more innovative and expensive technologies. This makes the protection of public welfare unsustainable, both in the short and the medium-long term. Therefore, the economic and financial sustainability of health systems and the optimal allocation of resources have become central issues in exercising health protection.1,2 Due to the growing concern of policy makers about the increase in health expenditure, more attention has been paid to economic efficiency issues even in health systems based on universalism principles. If in the past introducing a new technology imposed the main question of its effectiveness, now-a-days the assessment of its sustainability by the system cannot be neglected.3 In this context, the introduction, dissemination and implementation of evidence-based tools, aimed to the rationalization of the available resources, according to logic of social equity and economic sustainability, seems essential in the perspective of allocative efficiency. Therefore, there is a growing interest by policy and decision makers towards approaches to optimize use of available health technologies, also reducing their use or disinvesting from those that offer little or no benefit.1,2,4 During the last decade, the importance of disinvestment has been recognized by several countries. In September 2006, the Department of Health of the United Kingdom announced the new mandate for the National Institute for Health and Clinical Excellence (NICE) to support the National Health Service (NHS) in identifying non-effective technologies. To this purpose, NICE provided tools and recommendations to guide the process of health technology disinvestment.5–7 Progressively, other countries have payed specific attention to disinvestment, including Australia (with the first publications on the topic in 2007),8,9 the Swedish Council on Technology Assessment in Health Care (SBU), the West Scotland NHS and the Canadian Agency for Drugs and Technologies in Health (CADTH). In Spain, after the release- on 15 September 2006–of the Royal Decree 1030 on disinvestment, a project entitled ‘The identification, prioritization and evaluation of potentially obsolete health technologies’ was carried out by two regional HTA agencies.5 In 2010, a specific Interest Sub-Group on Disinvestment and Early Awareness was established within the HTA International Society (HTAi). It is aimed to be a key international center in sharing knowledge and expertise on methods for prioritization and evaluation of obsolete or low added value technologies and on disinvestment implementation in health systems.10 According to Elshaug AG et al., disinvestment consists of ‘withdrawing health resources from any existing health care practices, procedures, technologies or pharmaceuticals that are deemed to deliver little or no health gain for their cost and thus are not efficient health resource allocations’.8 The current economic context requires a re-organization and a re-allocation of resources, that can be pursued through the principle of ‘disinvest to re-invest’. However, disinvestment is not such a simple and straightforward process and makes it necessary to choose, based on evidence, the areas of intervention to be disinvested in order to re-invest.11,12 Oncology is a field where, because of high costs of health technologies and rapid innovation, disinvestment from clinical interventions with lower performance is crucial to invest in the best performing ones and ensure high levels of healthcare quality.13 Given the increased incidence and prevalence of oncological diseases and the availability of new therapeutic tools, the question of how to ensure access to new technologies and economic sustainability must be addressed.14,15 The aim of this study has been to investigate European countries’ opinions and views about disinvestment, in terms of fields of application, potential advocates and barriers specifically focusing on cancer care. Methods Study design and population A survey was conducted to address opinions and views of representatives of European countries on the topic of disinvestment, particularly regarding to its application in cancer care. The survey was part of a broader European project on cancer control and was carried out through a questionnaire sent to 53 representatives on 27 July 27 2015. Representatives were selected by the Italian Ministry of Health (MoH) among people belonging to MoH and/or HTA agencies and/or national institutions working in the field of oncology of each country and were addressed with two reminders. Questionnaire The questionnaire was first developed by a group of four experts in HTA and Health Management and was assessed in terms of content validity through a Delphi process involving five experts from the same fields and from the Italian MoH. The questionnaire consisted of two sections, one on disinvestment and the other on disinvestment in cancer care. Under each section, different topics were addressed. The first part tackled disinvestment policies put in place at the national level; use, objectives and advocates of disinvestment initiatives; barriers to the development and the adoption of disinvestment initiatives. The part on disinvestment in cancer care dealt with: waste of resources; areas and drivers of waste; need, targets, reasons for disinvestment policies; advocates of disinvestment policies. Each topic enclosed different statements evaluated through a Likert scale (strongly disagree; disagree; do not know; agree; strongly agree). Statistical analysis A descriptive analysis was carried out through absolute and relative frequencies. Tables were used to report results. Results A total of 17 questionnaires were filled in (response rate: 32.1%). All the respondents, except one, provided information on the country and the institution of origin. Respondents’ countries and institutions were as follows: Austria: Ministry of Health. Austria: Ludwig Boltzmann Institute of HTA. Basque Country: Osteba, Basque Office for HTA. Belgium: NIHDI (National Institute for Health and Disability Insurance). Croatia: Croatian Institute of Public Health. Cyprus: Ministry of Health. Germany: German Institute for Medical Documentation and Information. Hungary: National Institute of Oncology. Ireland: Department of Health. Italy: Ministry of Health. Lithuania: National Cancer Institute. Netherlands: Zorginstituut Nederland. Norway: Norwegian Directorate of Health. Poland: Ministry of Health. Spain: Ministry of Health (second round). Switzerland: Federal Office of Public Health FOPH. Sixteen out of 17 respondents reported their position: 8 (50%) were policy makers, 1 (6.3%) was a healthcare manager and 1 (6.3%) was a physician whereas the remaining 6 (37.5%) were other professionals. The results of the survey are reported separately for the first and the second part of the questionnaire. Disinvestment in general Nine (52.9%) respondents declared a disinvestment policy is in place in their country. Eleven respondents (around 65%) considered disinvestment initiatives useful to reduce unwarranted variations in clinical practice and allow a re-allocation of resources from low-value to high-value services/programmes. Twelve respondents (more than 70%) foresaw a role in improving overall quality of care reducing exposure to unsafe and ineffective interventions. Large agreement was reached on the utility of disinvestment activities for containing health care expenditures. Sixteen respondents (more than 90%) agreed or strongly agreed that disinvestment initiatives should be aimed at identifying obsolete technologies or interventions whose ineffectiveness has been clearly demonstrated. Fourteen (more than 80%) agreed or strongly agreed that disinvestment initiatives should be aimed at identifying low-value interventions whereas twelve (more than 70%) recognized a role in identifying interventions with uncertain or questionable clinical value and used inappropriately (table 1). Table 1 Use and objectives of disinvestment initiatives Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Table 1 Use and objectives of disinvestment initiatives Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment is likely to be used to Reduce unwarranted variations in clinical practice 1 (5.9) 4 (23.5) 1 (5.9) 7 (41.2) 4 (23.5) Contain health care expenditure 0 (0) 1 (5.9) 1 (5.9) 9 (52.9) 6 (35.3) Improve overall quality of care reducing exposure to unsafe and ineffective interventions 0 (0) 1 (5.9) 4 (23.5) 7 (41.2) 5 (29.4) Allow a re-allocation of resources from low-value to high-value services/programmes 0 (0) 3 (17.6) 3 (17.6) 7 (41.2) 4 (23.5) Allow a re-allocation of resources to support innovative technologies/interventions 0 (0) 2 (11.8) 6 (35.3) 7 (41.2) 2 (11.8) Make health professionals aware of cost-containment issues 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) 1 (5.9) Disinvestment should be aimed at identifying Obsolete interventions 0 (0) 1 (5.9) 0 (0) 7 (41.2) 9 (52.9) Low-value interventions 0 (0) 1 (5.9) 2 (11.8) 6 (35.3) 8 (47.1) Interventions whose ineffectiveness has been clearly demonstrated in well-designed studies and/or systematic reviews 0 (0) 1 (5.9) 0 (0) 4 (23.5) 12 (70.6) Interventions with still uncertain or questionable clinical value 1 (5.9) 1 (5.9) 3 (17.6) 7 (41.2) 5 (29.4) Interventions used inappropriately in clinical practice 1 (5.9) 1 (5.9) 3 (17.6) 5 (29.4) 7 (41.2) Interventions which are not cost-effective 1 (5.9) 1 (5.9) 5 (29.4) 7 (41.2) 3 (17.6) Respondents agreed or strongly agreed on the involvement of hospital managers, policy makers, researchers, clinicians, patients and their families, industries and citizens, respectively, in 13 out of 15 (86.7%), 13 out of 15 (86.7%), 10 out of 16 (62.6%), 9 out of 16 (56.3%), 4 out of 15 (26.7%), 4 out of 15 (26.7%) and 2 out of 14 (14.3%) cases. Twelve respondents (around 70%) recognized clinicians’ resistance to change and industries’ opposition as barriers to the implementation of disinvestment policies. More than half of respondents considered the following factors as barriers: lack of reliable and easily available information on current clinical practice and of scientific information on safety, effectiveness and costs of health care interventions and weak political willingness to undertake disinvestment initiatives. On the contrary, citizens’ and patients’ opposition was seen as a concern by less than half of respondents (table 2). Table 2 Barriers to disinvestment Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Table 2 Barriers to disinvestment Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Clinicians’ resistance to change 1 (5.9) 2 (11.8) 2 (11.8) 11 (64.7) 1 (5.9) Lack of reliable and easily available information on actual patterns of use of relevant intervention in daily clinical 0 (0.0) 7 (41.2) 0 (0.0) 7 (41.2) 3 (17.6) Lack of reliable scientific information on safety, effectiveness and costs of health care interventions (16) 0 (0.0) 7 (43.8) 0 (0.0) 5 (31.3) 4 (25.0) Weak political willingness to undertake such initiatives 1 (5.9) 4 (23.5) 2 (11.8) 8 (47.1) 2 (11.8) Citizens’ opposition 1 (5.9) 8 (47.1) 3 (17.6) 5 (29.4) 0 (0.0) Patients’ opposition 0 (0.0) 8 (47.1) 2 (11.8) 7 (41.2) 0 (0.0) Industries’ opposition (16) 0 (0.0) 4 (25.0) 1 (6.3) 8 (50.0) 3 (18.8) Disinvestment in cancer care Regarding disinvestment in cancer care two areas were analyzed, one about waste and another on policies. The synthesis of results is reported separately for the two sections. Waste Twelve out of 15 respondents (80%) providing their view affirmed that, in cancer care, the amount of resources wasted is significant. As far as the areas of waste, 11 out of 14 (78.6%) and 13 out of 14 (92.8%) respondents identified, respectively, the diagnostic and therapeutic activities at secondary care level (table 3). On the contrary, 8 out of 14 (57.1%) and 9 out of 14 (64.3%) respondents disagreed that tertiary care and prevention are areas at risk of waste (table 3). Table 3 Areas and drivers of waste Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Table 3 Areas and drivers of waste Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Areas at risk of waste (14) Prevention 4 (28.60) 5 (35.70) 2 (14.30) 3 (21.40) 0 (0) Secondary care-diagnostic approach 1 (7.10) 1 (7.10) 1 (7.10) 9 (64.30) 2 (14.30) Secondary care-therapeutic interventions 0 (0) 0 (0) 1 (7.10) 10 (71.40) 3 (21.40) Tertiary care (i.e. rehabilitation, patients’ management at the end of life) 3 (21.40) 5 (35.70) 4 (28.60) 1 (7.10) 1 (7.10) Waste is influenced by (16) Physicians’ defensive medicine 0 (0) 2 (12.50) 2 (12.50) 10 (62.50) 2 (12.50) Patients’ expectations 0 (0) 2 (12.50) 3 (18.80) 10 (62.50) 1 (6.30) Health care providers’ lack of accountability on how resources are used 0 (0) 3 (18.80) 4 (25) 6 (37.50) 3 (18.80) Physicians’ excessive reliance on supposedly innovative new technologies and drugs 0 (0) 2 (12.50) 2 (12.50) 8 (50.00) 4 (25.00) Lack of sound research information to guide clinical decisions 0 (0) 5 (31.30) 0 (0) 7 (43.80) 4 (25.00) Patients and their families being ill informed on the actual value of diagnostic and therapeutic interventions 0 (0) 2 (12.50) 1 (6.30) 9 (56.30) 4 (25.00) Lack of incentives in the system to a more rational use of resources 0 (0) 5 (31.30) 0 (0) 8 (50.00) 3 (18.80) Inadequate health professionals’ education and training 1 (6.30) 3 (18.80) 0 (0.00) 10 (62.50) 2 (12.50) Industry’s marketing pressure 1 (6.30) 1 (6.30) 1 (6.30) 7 (43.80) 6 (37.50) Twelve out of 16 respondents (75%) agreed inadequate health professionals’ education and training, physicians’ excessive reliance on supposedly innovative new technologies and defensive medicine may play a substantial role in determining waste (table 3). Furthermore, 13 out of 16 (more than 80%) considered bad information of patients and families on the value of diagnostic and therapeutic interventions and industries pressure as influent (table 3). Disinvestment policies Thirteen respondents (76.5%) believed disinvestment policies in oncology are necessary. Nonetheless, three respondents (17.6%) were not able to give their opinion, whereas one (5.9%) did not agree with the need for disinvestment policies in this field. Disinvestment policies were considered necessary, particularly to (in a descending order for importance): reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures, contain health care expenditures, obtain resources to make care more accessible to many patients, sustain valuable innovations in clinical practice, because there are still low-value interventions and too much variation in daily clinical practice (table 4). Table 4 Reasons and target of disinvestment policies Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) Table 4 Reasons and target of disinvestment policies Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) Strongly disagree Disagree Do not know Agree Strongly agree (%) (%) (%) (%) (%) Disinvestment policies are necessary because We need to contain health care expenditures in general (12) 0 (0) 1 (8.30) 0 (0) 9 (75.00) 2 (16.70) There is too much variation in clinical practice 0 (0) 2 (15.40) 2 (15.40) 7 (53.80) 2 (15.40) We need to reduce patients’ exposure to inappropriate diagnostic or therapeutic procedures 0 (0) 0 (0) 1 (7.70) 3 (23.10) 9 (69.20) Too many low-value interventions are still present in daily clinical practice 1 (7.70) 1 (7.70) 1 (7.70) 9 (69.20) 1 (7.70) We need to obtain resources to make care more accessible to many patients 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) We need to obtain resources to sustain valuable innovations in clinical practice 0 (0) 2 (15.40) 1 (7.70) 8 (61.50) 2 (15.40) Disinvestment policies should be targeted on (11) Drugs 0 (0) 0 (0) 0 (0) 6 (54.50) 5 (45.50) Diagnostic procedures 0 (0) 0 (0) 0 (0) 9 (81.80) 2 (18.20) Surgical treatments 1 (9.10) 2 (18.20) 3 (27.30) 4 (36.40) 1 (9.10) Palliative care 1 (9.10) 4 (36.40) 0 (0) 4 (36.40) 2 (18.20) Health services organizational models 1 (9.10) 2 (18.20) 1 (9.10) 4 (36.40) 3 (27.30) Screening 2 (18.20) 1 (9.10) 1 (9.10) 3 (27.30) 4 (36.40) In respect to the target of disinvestment policies, 11 out of 11 respondents (100%) identified drugs and diagnostic procedures as fields of disinvestment. Seven out of 11 (more than 60%) listed health services organizational models and screening. The situation was mixed regarding surgical treatments and palliative care (table 4). Disinvestment policies are seen to be supported by hospital managers first (11 out of 12 respondents, namely more than 90%, agreed on that). Eight out of 12 (75%) considered policy makers and researchers important. Half or more of respondents did not have a position with respect to the involvement of citizens and patients and families while 7 out of 12 (around 60%) disagreed on the involvement of industry. Finally, the role of clinicians was more debated. Discussion This survey showed disinvestment is applied in several countries as a tool for containing health care expenditures and identifying obsolete technologies or ineffective interventions. Alongside it, clinicians’ resistance to change and industries’ opposition are recognized as the most important barriers to the implementation of disinvestment policies. A first aspect arising from the survey that is worth considering is the extent of application of disinvestment policies across Europe. Even though more than 50% of responders reported that a disinvestment policy was in place in their countries, there is the need to get a consensus on the meaning of disinvestment to have a clear picture of the situation and make fair comparisons. If the goals of disinvestment are clear, the definition of a disinvestment policy, its framework and methods are less shared and standardized. According to the well-known definition of Elshaug et al.,3 disinvestment is ‘the process of (partially or completely) withdrawing health resources’ from low-value health technologies that represent an inefficient investment. Disinvestment is about resource re-allocation, not merely the promotion of the appropriate use of a health technology. In this respect, it can be misleading to consider disinvestment policies as aimed at cost-containing. The final goal is to identify and to disinvest from the so-called ‘obsolete’ technologies, namely those superseded by other technologies or demonstrated to be ineffective or harmful.16 We cannot conclude to what extent disinvestment policies meet these goals in the different countries, because it is well known that, in some contexts, disinvestment is attributed a negative connotation, namely ‘financially-motivated denial of care’.17 Budget concerns are a public health issue, and healthcare systems worldwide are facing the issue of wasteful health spending. About one-fifth of health expenditure in OECD countries makes a minimal or no contribution to people’s health improvement.18 According to Berwick and Hackbarth, one of the six main categories of health waste is represented by over-treatment.19 In fact, the overuse of a wide spectrum of health services as a source of waste and harmful to both patients and health systems, has been well documented.20 In particular, ordinary admissions, diagnostic imaging and drugs have been identified as the most overused services and, therefore, the main drivers of waste in healthcare.21 Our survey showed waste is a big concern also in cancer care. Waste is mostly seen in diagnostic and therapeutic areas, and the following play an important role: inadequate health professionals’ education and training; physicians’ excessive reliance on innovative new technologies; defensive medicine and bad information of patients. It should be considered that oncology is an area of fast increasing costs. The last can be attributable to the increased burden of oncological diseases and to the availability of innovative, more expensive therapies, the more aggressive care provided by physicians, the patients’ survival gains and, consequently, the increased treatment times.13 There is not much evidence on comparisons of cancer care costs across health systems that are challenging.22 Cancer-related healthcare costs across the European Union (EU) have been estimated by Luengo-Fernandez et al. to amount to €51.0 billion (4% of total EU healthcare expenditure), with inpatient care costs and drug expenditure accounting for 56% and 27% of cancer-related healthcare costs, respectively.23 In light of all abovementioned considerations, policies on disinvestment, in particular on cancer drugs, diagnostics and hospitalizations, should be fostered. But how to translate it into practice? The evidence offers two valuable approaches. The first one is represented by the Clinical Guidelines Program started in the United Kingdom, in 2001, by the NICE. This program, aimed to the development of guidelines focused on the improvement of standard of care, gives the opportunity to discuss not only new investments but also disinvestments in healthcare. During the guideline production process, indeed, the discontinuation or the optimization of practices/procedures of limited use or applied in an inefficient way are often discussed by the Guideline Development Group and some of the resulting suggestions are integrated in the ‘Do not do’ list available on the NICE Website. Among the clinical guidelines produced by the program, there are also disinvestment recommendations, i.e. on bladder cancer and advanced breast cancer.24 The second applies the league-table approach and proposes a framework to support the decision making of the NHS England’s Cancer Drugs Fund (CDF) by determining suitable cost-effectiveness thresholds. The authors concluded the adoption of this framework for the prioritization activity of the CDF would determine disinvestment from cost-ineffective drugs refundable by CDF.25 Furthermore, a recent review makes an overview of the implemented disinvestment program or structured experience to identify, prioritize and assess obsolete technologies. The paper shows most programs are implemented outside Europe, namely Australia and Canada.26 There are several papers addressing unnecessary, i.e. overused, interventions in cancer care.27–29 They have highlighted resulting health wastes and the importance of nationwide recommendations on the assessment of health technologies in light of disinvestment. The agreement on fields of waste and disinvestment policies sheds lights on how to pursue resource re-allocation in cancer care. Nonetheless, operational methods to put disinvestment in place are lacking, even though the scientific community is recognizing Health Technology Assessment (HTA) as a suitable approach,2 first of all because it allows the evaluation of several criteria12 at the same time and, second, because it employs a systematic approach. Third, HTA is a policy-oriented process born and used to support decision-making and it has been shown that the presence of an HTA agency is associated to the probability of having disinvestment programs in the country.26 Nevertheless, decision-making processes are undermined by several barriers. Generally, they entail lack of resources and data/evidence, but also clinicians’ resistance to change30 that has been identified as one of the major barriers to disinvestment policies in our survey. Clinicians’ resistance to change might have a nationwide, as well as a local, dimension. In the latter, political, social and clinical challenges may play an important role.31 Our survey also showed concerns about industries’ opposition whose role may be related to the lack of central commitment and to difficulties in collaborations, which have been described by the scientific evidence as ideological barriers to disinvestment.17 The clinicians’ resistance to change and industries’ opposition may be addressed by the adoption and the implementation of multi-stakeholders approaches such as the HTA. Because of the latter characteristic, its multi-disciplinary and evidence-based approach, HTA should be considered a pillar for investing and for disinvesting in health. Our work has some limits. First, the survey was performed on an opportunistic sample of representatives from European countries with a low response rate. This aspect might limit the transferability of results to the whole of Europe. Second, the questionnaire used to carry out the survey was not validated, limiting the generalizability of results and it only assessed personal knowledge and attitudes of responders, with no check on institutional documents. Nevertheless, to the best of our knowledge, our work is the first to address views and opinions on disinvestment across Europe and responders came back from all the European regions, allowing to get a first overview of the perspectives on this challenging topic. Acknowledgements The project is a part of the activities funded under the Italian National Centre for Disease Prevention and Control to support the Ministry of Health in co-ordinating and implementing the workpackage 5 of the European Joint Action CanCon. Funding The project is a part of the activities funded under the Italian National Centre for Disease Prevention and Control to support the Ministry of Health in co-ordinating and implementing the workpackage 5 of the European Joint Action CanCon. Conflicts of interest: None declared Key points The economic and financial sustainability of health systems and the optimal allocation of resources are central public health issues and there is a growing interest towards approaches to optimize the use of health technologies, while disinvesting from those of little or no value. Because of high costs of health technologies and rapid innovation, disinvestment from clinical interventions with lower performance is crucial in Oncology to ensure healthcare quality. Disinvestment is applied in several countries to contain health care expenditures and identify obsolete technologies/ineffective interventions. Clinicians’ resistance to change and industries’ opposition are recognized as the most important barriers to the implementation of disinvestment policies, while potential disinvestment targets in cancer are seen in diagnostic and therapeutic areas. Because of its multi-disciplinary, multi-stakeholders and evidence-based approach, HTA should be considered a pillar for investing and disinvesting in health. References 1 Donaldson C , Bate A , Mitton C , et al. Rational disinvestment . QJM: Monthly J Assoc Phys 2010 ; 103 : 801 – 7 . 2 Henshall C , Schuller T , Mardhani-Bayne L . Using health technology assessment to support optimal use of technologies in current practice: the challenge of ‘ disinvestment’. Int J Technol Assess Health Care 2012 ; 28 : 203 – 10 . Google Scholar CrossRef Search ADS PubMed 3 Elshaug AG , Hiller JE , Moss JR . Exploring policy-makers’ perspectives on disinvestment from ineffective healthcare practices . Int J Technol Assess Health Care 2008 ; 24 : 1 – 9 . Google Scholar CrossRef Search ADS PubMed 4 Prasad V , Cifu A , Ioannidis JP . Reversals of established medical practices: evidence to abandon ship . JAMA 2012 ; 307 : 37 – 8 . 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Oncology (Williston Park) 2012 ; 26 : 918 – 21, 924 . Google Scholar PubMed 14 Rotily M , Roze S . What is the impact of disease prevalence upon health technology assessment? Best Pract Res Clin Gastroenterol 2013 ; 27 : 853 – 65 . Google Scholar CrossRef Search ADS PubMed 15 Chabot I , Rocchi A . Oncology drug health technology assessment recommendations: canadian versus UK experiences . Clinicoecon Outcomes Res 2014 ; 6 : 357 – 67 . Google Scholar CrossRef Search ADS PubMed 16 Goodman CS . HTA 101: Introduction to Health Technology Assessment . Bethesda, MD : National Library of Medicine (US) . Available at: https://www.nlm.nih.gov/nichsr/hta101/HTA_101_FINAL_7-23-14.pdf (24 July 2017, date last accessed). 17 Rooshenas L , Owen-Smith A , Hollingworth W , et al. ‘I won't call it rationing…’: an ethnographic study of healthcare disinvestment in theory and practice . Soc Sci Med 2015 ; 128 : 273 – 81 . Google Scholar CrossRef Search ADS PubMed 18 OECD . 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Economic burden of cancer across the European Union: a population-based cost analysis . Lancet Oncol 2013 ; 14 : 1165 – 74 . Google Scholar CrossRef Search ADS PubMed 24 Drummond M . Clinical guidelines: a NICE way to introduce cost-effectiveness considerations? Value Health 2016 ; 19 : 525 – 30 . Google Scholar CrossRef Search ADS PubMed 25 Leigh S , Granby PA . Tale of two thresholds: a framework for prioritization within the cancer drugs fund . Value Health 2016 ; 19 : 567 – 76 . Google Scholar CrossRef Search ADS PubMed 26 Orso M , de Waure C , Abraha I , et al. Health technology disinvestment worldwide: overview of programs and possible determinants . Int J Technol Assess Health Care 2017 ; 33 : 239 – 50 . Google Scholar CrossRef Search ADS PubMed 27 Spence MT , Woodman C , Collins S , et al. Cervical smears–an opportunity for disinvestment? Br J Gen Pract 1996 ; 46 : 537 – 8 . Google Scholar PubMed 28 Bending MW , Trueman P , Lowson KV , et al. Estimating the direct costs of bowel cancer services provided by the National Health Service in England . Int J Technol Assess Health Care 2010 ; 26 : 362 – 9 . Google Scholar CrossRef Search ADS PubMed 29 O’Mahony JF , Normand C . HIQA’s CEA of breast screening: pragmatic policy recommendations are welcome, but ACERs reported as ICERs are not . Value Health 2015 ; 18 : 941 – 5 . Google Scholar CrossRef Search ADS PubMed 30 Harris C , Allen K , Waller C , Brooke V . Sustainability in health care by allocating resources effectively (SHARE) 3: examining how resource allocation decisions are made, implemented and evaluated in a local healthcare setting . BMC Health Serv Res 2017 ; 17 : 340 . Google Scholar CrossRef Search ADS PubMed 31 Polisena J , Clifford T , Elshaug AG , et al. Case studies that illustrate disinvestment and resource allocation decision-making processes in health care: a systematic review . Int J Technol Assess Health Care 2013 ; 29 : 174 – 84 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The European Journal of Public HealthOxford University Press

Published: Mar 12, 2018

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