Implementing disinvestment decisions in practice: a qualitative investigation of patient and clinician perspectives

• Published in: The Lancet (British edition) 2014-11, Vol.384, p.S67-S67
• Main Authors: Rooshenas, Leila, Dr, Owen-Smith, Amanda, PhD, Donovan, Jenny, Prof, Hollingworth, William, Prof
• Format: Article
• Language: English
• Subjects: Carpal tunnel syndrome; Internal Medicine; Overuse injuries
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(14)62193-0

Abstract Background With constrained National Health Service (NHS) budgets, commissioners are called upon to disinvest, which is the practice of stopping or restricting low-value health care. Despite the gain in momentum of research addressing how to disinvest, little is known about the consequences of disinvestment for affected stakeholders. We investigated how disinvestment is experienced by clinicians and patients, after introduction of eligibility criteria designed to restrict access to carpal tunnel decompression in two sociodemographically contrasting UK regions, where final decisions of whether patients fulfilled those eligibility criteria were made by surgeons (region 1) and commissioners (region 2). Methods Semi-structured interviews were conducted to elucidate surgeons' and patients' perspectives on the effect of disinvestment on their practices and experiences of care. Surgeons and patients were purposefully selected across four NHS hospitals. Hospital managers identified surgeons who conducted carpal tunnel decompression (n=9). Surgeons identified patients from clinic lists, to include a range of individuals who had received or not received surgery (n=17). Sampling continued until saturation, with data analysed thematically using constant comparison. Full ethics approval was received by the Southampton South Central B panel. All informants provided written informed consent before participation. Findings Surgeons felt able to maintain usual practice as long as they retained responsibility for applying disinvestment eligibility criteria themselves (region 1). Where eligibility was determined by third parties (region 2), surgeons expressed concern over non-experts making decisions using reductionist criteria that ignored intuitive clinical judgment. Most patients were unaware that disinvestment was occurring, and believed that care was solely determined by surgeons' assessments of what was clinically appropriate. Some patients encountered disinvestment unexpectedly, after they had already been informed (by general practitioners) that they required surgery; this led to anxiety that financial issues could prevent them from receiving the treatment they had come to believe they needed. Interpretation This research provides initial insights into how disinvestment is experienced by patients and clinicians in practice. Our findings indicate a need for future research into the effectiveness and acceptability of different approaches to implementing disinve