Processes, Contexts and Rationale for Disinvestment: A Critical Interpretive Synthesis

The Issue Pra ctical solutions are needed to support the appropriate use of available health system resources as countries are continually pressured to ‘do more with less’ in healthcare. Increasingly, health systems and organizations are exploring the reassessment of possibly obsolete, inefficient, or ineffective health technologies and potentially redirecting funds to those that are more effective and efficient. Such processes are often referred to as ‘ disinvestment ’, which is defined as “…the processes of (partially or completely) 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.” Significant effort has been invested in developing well-defined criteria and processes that draw on the best available evidence to assess the safety, effectiveness, and cost-effectiveness of new and emerging health technologies. Yet similar efforts have not been directed towards disinvestment. Failure to engage in disinvestment evaluations leads to inefficient allocation of limited health resources because health systems continue to provide reimbursement for technologies (and for those who deliver them) that may provide limited or no health gain. Principal Aim The goal of this knowledge synthesis is to conduct a critical interpretive synthesis (CIS) to gain further understanding about the rationale, political and health system contexts and process related to: whether, how and under what conditions health systems decide to pursue disinvestment (i.e., agenda setting or prioritization); how health systems have chosen to undertake disinvestment (i.e., policy development); and how health systems have implemented their disinvestment approach (i.e., policy implementation). Our approach We will use the critical interpretive synthesis approach (CIS), which has the core objective of developing theoretical frameworks based on insights and interpretation drawn from a broad range of relevant sources (i.e., not just those that meet particular design or quality criteria). We will systematically search (in collaboration with a librarian) and review literature, extract key findings from a purposive sample of articles using frameworks related to government agendas, policy development and implementation and health system contextual factors and then synthesize and integrate the findings to develop a framework about our core areas of interest. As a centre piece of our approach to end-of grant knowledge translation, we will convene a full-day workshop with Canadian and international policymakers and other stakeholders with the aim of soliciting targeted feedback about the framework (e.g., by identifying any gaps in the literature that we may want to revisit before finalizing it) and deliberating about barriers for developing and implementing approaches to disinvestment, strategies to address these barriers and about next steps that could be taken by different constituencies. Relevance and impact Disinvestment is an emerging field and there is a paucity of evidence to inform the prioritization, development and implementation of strategies in different contexts. Considering the lack of theoretical development, our CIS and the framework developed through it, will support the actions of those involved in the prioritization, development and implementation of disinvestment initiatives.