Potential for disinvestment in procedures of low health gain in Scotland

1. Potential for disinvestment in procedures of low health gain in Scotland Dr Sheila N Scott Director of Public Health Western Isles NHS Board 37 South Beach Street Stornoway, Isle of Lewis, HS1 2BB, Scotland, Sheila.Scott@wihb.scot.nhs.uk Priorities in Health Care Conference, November 2004

2. Objectives • Methodology/Project design • Results to date • Where next CONTENTS Priorities in Health Care Conference, November 2004

3. OBJECTIVES To undertake a stocktake across Scotland of Scottish Health Boards about any work to stop/curtail interventions of low or no health gain If so: what and by whom? What initiated such work - guidelines, HTA guidance, audit, Quality Improvement Scotland etc.? • Quantify nationally what the number of procedures might be • Calculate the opportunity cost/disinvestment potential • This project is on behalf of Scottish Directors of Public Health Priorities in Health Care Conference, November 2004

4. Orkney Highland Shetland Western Isles Grampian BACKGROUND 15 Health Boards Each Health Board has a Director of Public Health and denominator population from (25,000 - 1.1 million) Hospital activity for past 30 years Priorities in Health Care Conference, November 2004

5. METHODOLOGY Literature review in November ‘02 by Ann Lees, (Health Economist). Clinical Evidence A compendium of the best available research findings on common and important clinical questions, which is updated and expanded every six months. Published jointly by the BMJ Publishing Group and the American College of Physicians. Sample pages from the website http://www.bmjpg.com/evid99/index.html Evidence Based Medicine Bi-monthly, to survey at least 70 international medical journals to identify the key research papers that are scientifically valid and relevant to practice. These articles are selected according to scientific criteria and only those papers with direct message for practice are included. Covering internal medicine, general surgery, paediatrics, obstetrics, gynaecology, psychiatry, general practice, anaesthesiology and ophthalmology. http://www.bmjpg.com/data/ebm.htm Priorities in Health Care Conference, November 2004

6. ANALYSIS OF LITERATURE REVIEW Nb. “unknown” effectiveness does not = no effectiveness Priorities in Health Care Conference, November 2004

7. METHODOLOGY • Questionnaire for each Health Board designed and piloted in 2 Health Boards - one large one small. • Information Services Division, National Services Scotland approached re analysis of some sentinel procedures chosen from literature review, as a pilot. Priorities in Health Care Conference, November 2004

8. RESULTS Structured questionnaire pilot FEEDBACK • too much work required to make stocktake comprehensive • no central repository/responsibility for such work • confusion over disinvestment rationale - efficiency (access and frequency) vs low health gain • people too busy completing forms for other purposes • but happy with principle if supported Priorities in Health Care Conference, November 2004

9. Health Technology Section of Quality Improvement Scotland re ‘sentinel’ conditions and progress on full HTAs’ Tonsillectomy and grommets (ENT) Dilatation & Curettage (Gynaecological) Varicose Veins (Surgical) Grommets (ENT) But not reporting for some years. Priorities in Health Care Conference, November 2004

10. Results from ISD Rate per 100,000 population of ‘sentinel conditions’ Variation x2 - x9 (D&Cs) between each Health Board Priorities in Health Care Conference, November 2004

11. Secular trends downwards: Scotland but not uniform. Total number of ‘sentinel’ procedures was 17,000 in 2003/04 Priorities in Health Care Conference, November 2004

12. Clinicians will say “Some procedures will always be necessary” Number of procedures that could be avoided if the lowest rate was applied to all NHS Boards for ‘sentinel’ conditions. (total in Scotland in 2003/4=16,687) Priorities in Health Care Conference, November 2004

13. Are there significant correlations and differences between the rates in different Health Boards for different procedures? 1. Spearman’s product moment correlation - There is a significant correlation between the rates of tonsillectomy and rates of Varicose veins operations carried out by HB’s (r=.587,p=0.022) 2. ANOVA (1 way) Looked for significant variation in the rates between different HB types (RR, Mixed and Urban) - Results show that there is significant differences in rates for tonsillectomies (p=0.002) and varicose veins (p=0.001) between different HB types. 3.Post hoc Tukey test shows that there are no significant differences between Urban and Mixed but both are significantly different from Remote and Rural Priorities in Health Care Conference, November 2004

14. Possible explanations? • HB definitions (a mixture of density and no conurbation > 20,000) • Capacity/referral issues • Data population based not hospital based • Weighting by 1 or 2 clinicians • Other • Effect small in terms of numbers nationally Priorities in Health Care Conference, November 2004

15. CONCLUSIONS • Great potential to ‘save’ 6,500 operations from 4 ‘sentinel’ conditions, perhaps more • Health Boards and QIS, Scottish Medicines Consortium and others providing resources to promulgate/evaluate new technologies • Publication bias towards newer procedures/technologies • Nobody appears to have responsibility for stopping things that do not work or which may harm patients (reducing demand) • Dedicated resource to facilitate this required in Scotland Priorities in Health Care Conference, November 2004

16. What next?? • DsPH to discuss sentinel procedures with MDs after October presentation to MD’s)? • Role of Royal Colleges and others? • Who else should be involved and how? • Resource required to update literature and look at potential in other areas • Other issues??? • Potential for International collaboration Priorities in Health Care Conference, November 2004