Disinvestment Decisions Research Articles

Capacity Overhang and Corporate Disinvestment Decisions

Capacity Overhang and Corporate Disinvestment Decisions

OP102 Towards Universal Health Coverage: Health Technology Assessment Roadmap Development In The Emirate Of Abu Dhabi Involving The Whole Ecosystem

IntroductionThe mission of the Department of Health (DoH) of Abu Dhabi in the United Arab Emirates is to provide its population with a healthy life and world leading preventive and curative services. While the DoH has regulations in place to grant market approval to new health technologies, there is a need to develop a clear overall framework for reimbursement and disinvestment decisions. Establishing a structured health technology assessment (HTA) framework is critical for informing decisions on health technologies that offer value for money, with the aim of improving equitable access to health care, financial risk protection, and, ultimately, better health outcomes.MethodsDuring 2022, the DoH collaborated with the Radboud University Medical Center to explore the feasibility of applying an evidence-informed deliberative process (EDP) HTA approach through workshops and interviews involving all stakeholders in the ecosystem, such as policy makers, principal investigators, providers, patients and public groups, product manufacturers, payers, and purchasers. A situational analysis was conducted to collect stakeholders’ views and build EDPs. Based on this analysis, a structured roadmap was developed.ResultsThe comprehensive five-year roadmap to implement a holistic HTA framework in Abu Dhabi consisted of five major elements, starting with the establishment of an appropriate HTA policy framework as a foundation. Abu Dhabi should firmly establish its HTA structure and program (in one to two years), and at the same time invest in developing and retaining HTA training capacity so that over time (within three to five years) the country can build up its own expertise to sustain the program. This needs to be accompanied by continuous awareness raising among all relevant stakeholders.ConclusionsThis roadmap is the first and most important step toward implementing a holistic HTA framework in Abu Dhabi. Technical work needs to be complemented by continuously raising awareness and involving all relevant stakeholders. Looking at the initial results and international benchmarks, HTA will significantly contribute to achieving a sustainable, high quality healthcare system.

Competition, investment reversibility, and equity risk premium

This paper investigates the role of investment reversibility in determining the relationship between product market competition and equity risk premium. We develop a unified real-option framework involving corporate investment and disinvestment decisions in a continuous-time Cournot–Nash equilibrium. The effect of competition on a firm’s risk premium induced by contraction options is negative and similar to that on the risk premium induced by expansion options; however, for assets in place, more competition results in a higher risk premium by increasing operating leverage. Notably, investment reversibility rather than product market demand moderates the competition-risk premium relationship. Our model predicts that the equity risk premium is more negatively correlated with the level of competition if investments are more reversible because firms are more likely to adjust their capacity in response to uncertain demand and this flexibility attenuates the positive operating leverage effect. We find robust empirical evidence to support our theoretical prediction.

Capacity overhang and corporate disinvestment decisions

AbstractWe use a stochastic frontier model to estimate a firm's capacity overhang. We find that excess capacity is positively related to a drop in new capital expenditures, an accumulation of depleted long‐term assets, and outright sales of investment assets. However, the sale of long‐term assets (property, plant, and equipment [PP&E]) peaks for intermediate levels of excess capacity and then declines. We attribute this to growth options. We test for evidence of a preference ordering in the firm's choice of responding to excess capacity and find evidence for a pecking order in firm disinvestment, where sales of long‐term assets are a measure of last resort.

PP132 Disinvestment Initiatives In Health Care: A Scoping Review Of Systematic Reviews

IntroductionDisinvestment of ineffective, low value technologies is growing as a priority for international health policy in order to improve quality and maximize value in health care. Different strategies have been implemented at the international and national level using various methods of evidence gathering and technical assessment. However, the success of these initiatives is mixed, with fewer than half of the empirical studies reporting reductions in the use of low value services.This review explored the role of stakeholders in the disinvestment process by describing the initiatives and analyzing the methods used for reassessment. We also identified the facilitators and barriers related to disinvestment implementation.MethodsThis scoping review was guided by the JBI Manual for Evidence Synthesis and the PRISMA statement for scoping reviews. Strategic literature searches were performed to identify published reviews on disinvestment in health care using the MEDLINE, Web of Science, and Scopus databases. Data were extracted using a predesigned form and then synthesized narratively to identify similarities and differences across the approaches according to prespecified domains.ResultsSixteen reviews were included. We identified various disinvestment initiatives across 16 countries, with a minimum of 34 initiatives at different levels of implementation and with various agencies responsible for the activities. Two of the most used methods for facilitating disinvestment decisions were program budgeting and marginal analysis (PBMA) and health technology assessment (HTA). Stakeholder involvement was the most important aspect to be addressed since it acts as both a facilitator and a barrier in implementing disinvestment initiatives. Meaningful engagement may be strengthened with continuous stakeholder participation, transparency in methods and processes, and ongoing knowledge transfer.ConclusionsThis scoping review highlights the role of stakeholder involvement in disinvestment, which is a double-edged sword because it both facilitates and hinders disinvestment implementation. The most common methods for assessing candidates for disinvestment are PBMA and HTA, but there is a lack of clarity on which HTA dimension is suitable for a disinvestment process.

If you were a policymaker, which treatment would you disinvest? A participatory value evaluation on public preferences for active disinvestment of health care interventions in the Netherlands.

Currently, it is not known what attributes of health care interventions citizens consider important in disinvestment decision-making (i.e. decisions to discontinue reimbursement). Therefore, this study aims to investigate the preferences of citizens of the Netherlands toward the relative importance of attributes of health care interventions in the context of disinvestment. A participatory value evaluation (PVE) was conducted in April and May 2020. In this PVE, 1143 Dutch citizens were asked to save at least €100 million by selecting health care interventions for disinvestment from a list of eight unlabeled health care interventions, described solely with attributes. A portfolio choice model was used to analyze participants' choices. Participants preferred to disinvest health care interventions resulting in smaller gains in quality of life and life expectancy that are provided to older patient groups. Portfolios (i.e. combinations of health care interventions) resulting in smaller savings were preferred for disinvestment over portfolios with larger savings. The disinvestment of health care interventions resulting in smaller health gains and that are targeted at older patient groups is likely to receive most public support. By incorporating this information in the selection of candidate interventions for disinvestment and the communication on disinvestment decisions, policymakers may increase public support for disinvestment.

A Review of Economic Models Submitted to NICE's Technology Appraisal Programme, for Treatments of T1DM & T2DM.

Background: In the UK, 4.7 million people are currently living with diabetes. This is projected to increase to 5 million by 2025. The direct and indirect costs of T1DM and T2DM are rising, and direct costs already account for approximately 10% of the National Health Service (NHS) budget. Objective: The aim of this review is to assess the economic models used in the context of NICE’s Technology Appraisals (TA) Programme of T1DM and T2DM treatments, as well as to examine their compliance with the American Diabetes Association’s (ADA) guidelines on computer modelling. Methods: A review of the economic models used in NICE’s TA programme of T1DM and T2DM treatments was undertaken. Relevant TAs were identified through searching the NICE website for published appraisals completed up to April 2021. The review also examined the associated Evidence Review Group (ERG) reports and Final Appraisal Documents (FAD), which are publicly accessible. ERG reports were scrutinised to identify major issues pertaining to the economic modelling. The FAD documents were then examined to assess how these issues reflected on NICE recommendations. Results: Overall, 10 TAs pertaining to treatments of T1DM and T2DM were identified. Two TAs were excluded as they did not use economic models. Seven of the 8 included TAs related to a novel class of oral antidiabetic drugs (OADs), gliflozins, and one to continuous subcutaneous insulin infusion (CSII) devices. There is a lack of recent, robust data informing risk equations to enable the derivation of transition probabilities. Despite uncertainty surrounding its clinical relevance, bodyweight/BMI is a key driver in many T2DM-models. HbA1c’s reliability as a predictor of hard outcomes is uncertain, chiefly for macrovascular complications. The external validity of T1DM is even less clear. There is an inevitable trade-off between the sophistication of models’ design, their transparency and practicality. Conclusion: Economic models are essential tools to support decision-making in relation to market access and ascertain diabetes technologies’ cost effectiveness. However, key structural and methodological issues exist. Models’ shortcomings should be acknowledged and contextualised within the framework of technology appraisals. Diabetes medications and other technologies should also be subject to regular and consistent re-appraisal to inform disinvestment decisions. Artificial intelligence could potentially enhance models’ transparency and practicality.

Disinvestment in healthcare: a scoping review of systematic reviews

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

Risk aversion, trust in institutions and contingent valuation of healthcare services: trying to explain the WTA-WTP gap in the Dutch population

BackgroundThe preferences of citizens are a basic element to incorporate into the decision-making process when planning health policies. Contingent valuation (CV) is a common method for calculating the value for citizens that new technologies, interventions, and the provision of services or policies have. However, choosing the correct CV tool may not be a neutral decision. This work aims to assess the substitution of a healthcare service by comparing valuation differences between the willingness to pay (WTP) for the maintenance of the service versus the willingness to accept compensation (WTA) for its substitution, both of which are related to subject characteristics, with a particular focus on trust in institutions and risk aversion.MethodsA CV study was designed to study Dutch population preferences when physician assistants replace anaesthesiologists. Differences between the distributions of WTA and WTP were compared through full decomposition methods, and conditional quantile regression was performed.ResultsNearly two-thirds of surveyed citizens expressed null values for WTA and WTP. The other third systematically reported a value of WTA higher than that of WTP, which increased further with lower income and the possible presence of a strategic bias. In contrast, being more than 65 years old, having trust in government, and preferring anaesthesiologists decreased the WTA-WTP difference. Risk aversion had no clear association with the WTA-WTP gap.ConclusionsKnown differences between the perceived value of health services from the perspective of gains and losses could be related to people’s characteristics. Trust in government but not aversion to risk was related to the WTA-WTP differences. Identifying a profile of citizens who are averse to losing health services should be considered when designing and implementing health services or interventions or making disinvestment decisions.

Comparison of real estate appraisal methodologies based on artificial intelligence

The aim of this paper is to present and compare models that estimate the value of a property according to its characteristics. This information can be required by, for example, potential investors in the real estate markett. In this way, they will be able to compare the offer price of the property with the value obtained by the model, before making investment or disinvestment decisions. In this paper we apply supervised (regression tree, random forerst, nearest neighbour, SVM) and unsupervised (clustering) data analysis methods in order to estimate the value of dwellings located in the city of Madrid, Spain. It is found that the housing characteristic that most influences the price is the surface area, and to a lesser extent the number of rooms, whether the building has a lift, the number of bathrooms and whether the building has a car park. The best method of estimation, according to the MAPE, was the random forest method.

Factors affecting procurement of wound care products: a qualitative study of hospital managers and clinicians.

Objective To identify factors that influence procurement and disinvestment decisions for wound care products in the acute care setting. Methods A qualitative descriptive study was undertaken. Eighteen face-to-face semi-structured interviews were conducted with purposively sampled senior clinical and non-clinical managers from three Australian acute care hospitals with responsibility for consumables procurement and disinvestment decisions. Data were coded and analysed thematically. Results Three main themes (Systems and triggers, Evidence-free zone, Getting the governance right) with sub-themes were identified that reflect that: (1) procurement processes were often ad hoc and workarounds common. Disinvestment was poorly understood and opportunities were missed to reduce use of low value products ; (2) product selection was commonly based on clinician preference, contractual obligations and information from industry representatives; and (3) improved evidence-based governance and processes are needed to connect procurement and disinvestment decisions and to minimise the influences of clinician preference and industry representatives on product selection. Conclusions Systematic and evidence-based approaches are needed to strengthen procurement and disinvestment decisions related to consumables such as wound care products and to minimise the purchasing of low-value products Decision-making frameworks should consider cost and clinical effectiveness and enable the identification of opportunities to disinvest from low-value products. What is known about the topic? High volume-low unit cost healthcare consumables such as wound care products are a major component of healthcare expenditure. Disinvestment from low-value wound care products has potential to improve patient outcomes and optimise health resources. What does this paper add? Disinvestment was poorly understood and considered in isolation from procurement decisions. Procurement decisions were rarely informed by research evidence, with clinicians exercising considerable freedom to make purchasing decisions based on product preference and industry information. Frameworks and guidelines are needed to guide procurement and disinvestment decision-making for wound care products. What are the implications for practitioners? New models for procurement and disinvestment decision-making for wound care products could help to strengthen decision-making processes, facilitate evidence-based product choices and also prompt consideration of removal of low-value products.

4.F. Round table: Fair processes and fair pricing: examining deliberative processes and the role of HTA for UHC

Abstract Achieving Universal Health Coverage (UHC) represents a global commitment and is part of the Sustainable Development Goals. The UHC Political Declaration states 'high prices for some health products, and inequitable access to such products within and among countries, as well as financial hardships associated with high prices of health products continue to impede progress towards achieving UHC'. The rapid rise and cost of new therapies has led to polarised discussions on what constitutes a fair price, whether R&D costs justify the prices, and whether the current intellectual property protection framework is appropriate for global public health goods. In this light, we are progressively moving from value-based pricing to fair and sustainable pricing; fair pricing carries the notion of just proportion of value to all involved parties. To render this possible, all relevant stakeholders need to be involved in transparent processes characterized by democratic representation, with communication and information exchanges safeguarded to establish what is fair and what is sustainable. HTA can help towards this as it is a tool to inform pricing and planning decisions, potential investment or disinvestment decisions, decisions on cross-country collaboration for price negotiation, and state decisions to invest in R&D or in manufacturing, or to negotiate supply. HTA allows capturing the needs and preferences of users of the health system and carries the potential to determine societal value in relation to public reimbursement. Governance mechanisms allowing HTA to be organised as a continuous evidence-informed deliberative process could function as the necessary exchange platform for all relevant stakeholders. For an interdisciplinary examination of deliberation in HTA, and to establish the key attributes the notion of fairness can carry, it is important to bring together different perspectives. Evidence-informed decision-making, and processes which ensure transparency and legitimacy, may require changes in evidence generation, but, also, in the legislative, regulatory and pricing frameworks. What is already feasible will be discussed, e.g., cases where information exchange and centralised procurement resulted in improved negotiation, along with how sound governance structures could support stakeholder representation and involvement. The principal objectives of the workshop are 1) to explore notions of fairness and approaches deemed feasible and relevant, and 2) to identify, through multistakeholder dialogue, key attributes for ensuring legitimate decision-making, and UHC incl. through fair pricing. Academia, HTA agencies, incl. from Low- and Middle-Income Countries (LMICs), the World Health Organization, payers, and patients are represented in the panel. Each speaker will make a 12-min presentation, followed by a 30-min discussion between panel and audience. An interactive element will allow the audience to respond to Yes/No statements and submit questions. Key messages Deliberative processes can contribute to establish multi-stakeholder agreement on what constitutes fair pricing. HTA as a deliberative process can critically contribute towards legitimate decision-making.

“Magnitude of clinical benefit” of solid tumour drugs and their real-world application in the Austrian health care setting

ObjectiveInsufficient evidence for robust decision-making especially for cancer drugs increases the importance of systematic assessments of clinical benefits and the actual real-world application. Therefore, we aimed to assess the clinical benefit of recently approved solid cancer drugs in Europe and their real-world application in the Austrian inpatient setting and day-patient settings. MethodsOur data basis was Austrian routine inpatient data provided by the Main Association of Austrian Social Security Institutions. All adult patients diagnosed with cancer in a public Austrian hospital between 2012 and 2016 were included. The clinical benefit of originator solid cancer drugs approved by the European Medicines Agency between 2009 and 2016 was assessed by applying two versions (original versus adapted) of the Magnitude of Clinical Benefit Scale (MCBS) from the European Society of Medical Oncology (ESMO). ResultsOnly a minority of our investigated cancer indications met the criteria for meaningful clinical benefit (MCB) independently of the applied ESMO-MCBS version (original: n = 6/33, adapted: n = 3/33). The threshold for MCB was most commonly met by breast cancer drugs. Furthermore, ten cancer drugs with highly rated indications (ESMO-MCBS: 4–5/B-A) were not included in the Austrian hospital benefit catalogue until 2016. Moreover, our results demonstrate that just a few of the ten most frequently applied cancer therapies were part of our ESMO-MCBS analyses. ConclusionSystematically collected solid real-world data can contribute to evidence-based reimbursement and disinvestment decisions and thereby improve equal access to health care across all nine Austrian federal states.

A lab test on the decision not to decide

Decisions are often postponed even when future profits are not expected to compensate for the losses. This is especially relevant for financial and entrepreneurial disinvestment choices, as investors often have a disposition to hold on to losing assets for too long. We use an experiment with real real-options to study one possible behavioral motivation. Studies in psychology suggest that individuals have different styles of handling the stress involved in making decisions. We find that participants' styles of decision-making and risk aversion as well as the interaction of those can assist in predicting the likelihood that the participants will make investments and the timing of their disinvestment decisions. We also find the overall structure of the findings to be in line with a planner–doer model.

Formulating an Ethics of Pharmaceutical Disinvestment.

There is growing interest among pharmaceutical policymakers in how to "disinvest" from subsidized medicines. This is due to both the rapidly rising costs of healthcare and the increasing use of accelerated and conditional reimbursement pathways which mean that medicines are being subsidized on the basis of less robust evidence of safety and efficacy. It is crucial that disinvestment decisions are morally sound and socially legitimate, but there is currently no framework to facilitate this. We therefore reviewed the bioethics literature in order to identify ethical principles and concepts that might be relevant to pharmaceutical disinvestment decisions. This revealed a number of key ethical considerations-both procedural and substantive-that need to be considered when making pharmaceutical disinvestment decisions. These principles do not, however, provide practical guidance so we present a framework outlining how they might be applied to different types of disinvestment decisions. We also argue that, in this context, even the most rigorous ethical reasoning is likely to be overridden by moral intuitions and psychological biases and that disinvestment decisions will need to strike the right balance between respecting justifiable moral intuitions and overriding unjustifiable psychological impulses.

The art and science of priority-setting: assessing the value of Public Health England's Prioritization Framework.

ABSTRACTBackgroundFindings are presented from the evaluation of Public Health England’s (PHE) Prioritization Framework (PF) aimed to assist local authority commissioners with their public health investment and disinvestment decisions. The study explored the take up of the PF in three early adopter local authority settings.MethodsSemi-structured interviews (n = 30) across three local authorities supplemented by participant observation of workshops.ResultsParticipants acknowledged that the PF provided a systematic means of guiding priority-setting and one that encouraged transparency over investment and disinvestment decisions. The role performed by PHE and its regional teams in facilitating the process was especially welcomed and considered critical to the adoption process. However, uptake of the PF required a significant investment of time and commitment from public health teams at a time when resources were stretched. The impact of the political environment in the local government was a major factor determining the likely uptake of the PF. Ensuring committed leadership and engagement from senior politicians and officers was regarded as critical to success.ConclusionsThe study assessed the value and impact of PHE’s PF tool in three early adopter local authorities. Further research could explore the value of the tool in aiding investment and disinvestment decisions and its impact on spending.

A framework to guide strategic disinvestment in roadway infrastructure considering social vulnerability

Abstract Strategic disinvestment involves a conscious reallocation of funds to prioritize transportation infrastructure assets in terms of their importance or criticality, and then deliberately shifting limited resources away from lower priority assets toward higher priority assets. While previous investment paradigms considered the economic implications of expanding or maintaining assets versus the alternative of no expansion or no maintenance, disinvestment considers whether it is realistic to attempt to maintain all assets according to their original standards, or if performance standards should be changed or ownership transferred. While the concept of disinvestment has received attention in recent years, there is no established framework for disinvestment actions, potential travel impacts associated with disinvestment actions have not been widely examined, and it is unclear how disinvestment may affect socially vulnerable populations. In this paper, we present a novel framework to guide disinvestment decisions. The framework identifies different disinvestment actions and illustrates the savings, costs, and control tradeoffs associated with those actions. Each action offers different cost-savings and is associated with varying levels of reduced responsibility or obligation. We next introduce a measure of social vulnerability referred to as the Disinvestment Vulnerability Index (DVI) to help identify socially vulnerable populations impacted by disinvestment. We then propose a methodology for identifying a set of least critical or “non-essential” roadway assets as initial candidates for disinvestment, and introduce an approach for quantifying the potential effect of asset-specific disinvestment actions on vulnerable populations. The suggested approach allows decision-makers to “take the first step” in selecting an initial set of potential disinvestment candidates by identifying assets that have a minimal disruptive effect on network-wide travel, while simultaneously considering accessibility and mobility issues related to socially vulnerable populations. We illustrate the approach in the state of Vermont using the state’s travel demand model and data obtained from the U.S. Census.

Shifting the Gravity of Spending: Assessing the impact of PHE’s Prioritisation Framework

Abstract Background Findings are presented from the evaluation of Public Health England’s (PHE) new Prioritisation Framework (PF) conducted between September 2017 and December 2018 aimed to help local authority commissioners with their public health investment and disinvestment decisions. The study explored the take up of the PF in three early adopter local authority settings. Methods Data collection was based on semi-structured interviews (n = 30) across three local authorities supplemented by participant observation of workshops and data concerning the implementation process as well as spend and outcomes both before and, where possible, after using the PF. Results Participants acknowledged that the PF provided a systematic way to guide prioritisation decisions and one that encouraged transparency over investment and disinvestment decisions. The role performed by PHE and its regional teams in facilitating the process was especially welcomed and considered to be critical to the adoption process. However, uptake of the PF required a significant investment of time and commitment from public health teams at a time when resources were stretched. The impact of the political environment in local government was a major factor determining the likely uptake of the PF. Ensuring committed leadership and engagement from senior politicians and officers was regarded as critical to success. Conclusions The study assessed the value of the PF and the processes surrounding its implementation and use. Further research could further explore the value of the tool in aiding investment and disinvestment decisions and its impact on spending. Key messages The PF provides a platform for engaged and informed deliberation about priorities and does so in an open, structured and transparent manner. Organisational and political context in which prioritisation occur shape the adoption of the PF tool.

Public perspectives on disinvestments in drug funding: results from a Canadian deliberative public engagement event on cancer drugs

BackgroundDecisions relating to the funding of new drugs are becoming increasingly challenging due to a combination of aging populations, rapidly increasing list prices, and greater numbers of drug-indication pairs being brought to market. This is especially true in cancer, where rapid list price inflation is coupled with steeply rising numbers of incident cancer cases. Within a publicly funded health care system, there is increasing recognition that resource allocation decisions should consider the reassessment of, and potential disinvestment from, currently funded interventions alongside new investments. Public input into the decision-making process can help legitimize the outcomes and ensure priority-setting processes are aligned with public priorities.MethodsIn September 2014, a public deliberation event was held in Vancouver, Canada, to obtain public input on the topic of cancer drug funding. Twenty-four members of the general public were tasked with making collective recommendations for policy-makers about the principles that should guide funding decisions for cancer drugs in the province of British Columbia. Deliberative questions and decision aids were used to elicit individuals’ willingness to make trade-offs between expenditures and health outcomes.ResultsParticipants discussed the implications of disinvestment decisions from cancer drugs in terms of its impact on patient choice, fairness and quality of life. Their discussions indicate that in order for a decision to disinvest from currently-funded cancer drugs to be acceptable, it must align with three main principles: the decision must be accompanied by significant gains, described both in terms of cost savings and opportunities to re-invest elsewhere in the health care system; those who are currently prescribed a cancer drug should be allowed to continue their course of treatment (referred to as a continuance clause, or “grandfathering” approach); and it must consider how access to care for specialized populations is impacted.ConclusionsThe results from this deliberation event provide insight into what is acceptable to British Columbians with respect to disinvestment decisions for cancer drugs. These recommendations can be considered within wider health system decision-making frameworks for funding decisions relating to all drugs, as well as for cancer drugs.

Disinvestment Activities and Candidates in the Health Technology Assessment Community: An Online Survey.

As healthcare decision makers continue to face challenges in health services delivery to their patients, disinvestment programs are being established for a sustainable healthcare system. This study aimed to collect data and information by means of a survey of disinvestment candidates and ongoing disinvestment projects in the health technology assessment (HTA) community. An online survey was conducted to collect information on disinvestment candidates and activities from members of the Health Technology Assessment International Disinvestment & Early Awareness Interest Group, the EuroScan International Network and International Network of Agencies for Health Technology Assessment. Among the 362 invitees, twenty-four unique responses were received, and almost 70 percent were involved in disinvestment initiatives. The disinvestment candidates identified represented a range of health technologies. Evidence or signaling of clinical ineffectiveness or inappropriate use typically led to the nomination of disinvestment candidates. Health technology assessments and reassessments were usually conducted to evaluate the technology in question, and decisions usually led to the limited use of the technology. Barriers to disinvestment decisions included the strength of interest and advocacy groups, insufficient data for assessments, a systematic decision process and political challenges, while obstacles to their implementation were clinicians' reluctance and insufficient funding and incentives. The survey results suggested that disinvestment activities are occurring in the HTA community, especially in the public sector. Future research can further investigate the processes and methods used to reach and implement disinvestment decisions from our survey respondents and explore to form closer ties between the HTA and clinical communities.