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Disinvestment is critical for ensuring the long-term sustainability of health-care services. Key barriers to disinvestment are heterogeneity between research and clinical settings, absence of evidence of effectiveness of some health technologies, and exposure of patients and organizations to risks and poor outcomes. We aimed to develop a feasible research design that can evaluate disinvestment in health technologies of uncertain effectiveness or cost-effectiveness. This article (1) establishes the need for disinvestment methodologies, (2) identifies the ethical concerns and feasibility constraints of conventional research designs for this issue, (3) describes the planning, implementation, and analytical framework for a novel disinvestment-specific study design, and (4) describes potential limitations in application of this design. The stepped-wedge, roll-in cluster randomized controlled trial can facilitate the disinvestment process, whereas generating evidence to determine whether the decision to disinvest was sound in the clinical environment. A noninferiority research paradigm may be applied to this methodology to demonstrate that the removal of a health technology does not adversely affect outcomes. This research design can be applied across multiple fields and will assist determination of whether specific health technologies are clinically effective, cost-effective, and safe.

Abstract Objective To explore cost-efficiency, safety and acceptability of trans-disciplinary advanced allied health (AH) practitioners for acute adult general medicine inpatients. Design Quasi-experimental feasibility study. Setting Three acute general medical units in an Australian urban hospital. Participants Two hundred and fifty-six acute hospital inpatients. Main Outcome Measures Cost-efficiency measures included AH service utilization and length of stay (LOS). Patient outcomes were functional independence, discharge destination, adverse events, unplanned admissions within 28 days, patient satisfaction and quality of life data on admission, and 30 days post-discharge. Ward staff were surveyed regarding satisfaction with the service model, and advanced health practitioners (AHPs) rated their confidence in their own ability to meet the performance standards of the role. Results Patients allocated to AHPs (n = 172) received 0.91 less hours of AH intervention (adjusted for LOS) (95% confidence intervals (CI): −1.68 to −0.14; P = 0.02) and had 1.76 days shorter LOS relative to expected (95%CI: 0.18–3.34; P = 0.03) compared with patients receiving standard AH (n = 84). There were no differences in patient outcomes or satisfaction. AHPs demonstrated growth in job satisfaction and skill confidence. Conclusions Trans-disciplinary advanced AH roles may be feasible and cost-efficient compared with traditional roles for acute general medical inpatients. Further development of competency frameworks is recommended.

ObjectivesTo adapt and apply a model for evaluating the functional benefits and cost efficiency of specialist inpatient rehabilitation to the Australian context, comparing functional outcomes and savings in the cost of ongoing care after acquired brain injury.DesignAn observational cohort analysis of prospectively collected clinical data from admission to discharge, with follow-up to 3 years.SettingA newly established state-wide inpatient postacute rehabilitation unit in Victoria, Australia for patients with moderate to severe acquired brain injury.ParticipantsThis study included consecutive patients admitted to the programme during its first 2 years’ operation (January 2016 to December 2017). Inclusion criteria consisted of complete outcome measures recorded on admission and discharge, total n=196, mean age 44.6 years (range 17–78), males:females 72:28%, aetiology:trauma n=124 (63%), stroke n=42 (21%), diffuse n=18 (9%) and other-mixed n=12 (7%).InterventionsSpecialist inpatient multidisciplinary rehabilitation.Outcome measuresDependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPCNA); Functional independence: UK Functional Assessment Measure. Cost efficiency: (a) Time is taken to offset rehabilitation costs by savings in NPCNA-estimated costs of ongoing care and (b) net projected lifetime savings.ResultsMedian length of stay 75 (IQR: 33.5–169.5) days, mean episode costs were $A147 044 (95% CI $A126 436, $A167 652). There was a significant reduction in dependency between admission and discharge on all measures (Holm-Bonferroni corrected p<0.001) which was sustained at follow-up in those traced at 1–3 years. Savings were greatest in the highest-dependency group. Estimated mean overall reduction in ‘weekly care costs’ was $A7206, offsetting the cost of rehabilitation within 5.53 months (95% CI 2.27, 8.78). Mean projected net lifetime savings were $A13.4 million (95% CI $A11.4, $A15.4) per patient.ConclusionsThis study provides proof of principle for use of the NPCNA cost-efficiency model outside the UK and yields further evidence that rehabilitation for patients with complex disabilities represents value for money. For every dollar spent on inpatient rehabilitation in this cohort, an estimated $A91 was saved in ongoing care costs.

Objectives. This paper describes the development, implementation and preliminary results of a collaborative pilot project aimed at reducing the time hospital-based patients with cognitive impairments spend waiting for the allocation of legally appointed Advocate Guardian decision makers from the Office of the Public Advocate (OPA). The aim of the study was to investigate the effect of increased availability of public advocate guardians on guardian allocation waits, patient discharge outcomes and healthcare system demand. Methods. A multi-institutional pilot program created a dedicated hospital guardian team within OPA, funded by the health networks, to reduce the time to guardian allocation for patients within each network. A multisite, quasi-experimental historical control group design was used, with initial data collection over 12 months, followed by study of 12-month postimplementation cohorts. Results. Under the pilot program, the time from guardianship order lodgement to guardian allocation decreased significantly from 46.5 to 22.9 days, halving the average time hospital-based patients spend waiting for a guardian (difference -23.55 days, two-sample t(154) = -6.575, P< 0.0001, 95% confidence interval [-30.65, -16.48].). Mean total length of stay decreased from 163.2 to 148.5 days. The estimated value of the reduction in allocation wait time was A $15 473 per patient, or A$ 5 of resources released per A$1 spent on increased staffing. Conclusions. Direction of a small amount of resources from health services to staff within OPA appears to have created much greater savings for the health services involved. The pilot program has reduced the period of time vulnerable patients spend waiting in hospital for a guardian.