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Supplemental Table 1: Disinvestment Candidates and DecisionsNo.TechnologyCountryTargeted PopulationIndicationAlternative Reason for Proposed DisinvestmentDecisionMedical Services or Procedures1Liver biopsyAustraliaAdult men and womenHepatitis, cirrhosisFibroScanAlternative with better clinical effectiveness/safety profile available Alternative with better cost-effectiveness availableComplete removal2Surgical removal of pacemaker leadsAustraliaAdults with pacemakersThoracic surgeryLaser lead extractionAlternative with better clinical effectiveness/safety profile available Alternative with better cost-effectiveness available Complete removal3Extracranial-intracranial bypassSpainPrevention of carotid occlusionStrokeLife style changes, pharmacological interventions to treat dislipemias, hypertension and cholesterol levelsEvidence/signalling of inadequate safetyEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useComplete removal4Transurethral resection of the prostate AustraliaMen > 50 yearsBenign prostatic hypertrophyGreen Light laserAlternative with better clinical effectiveness/safety profile available Alternative with better cost-effectiveness available Limited use5TonsillectomySpainPediatric populationSleep apnea-Evidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useLimited use6TonsillectomySpainPediatric populationContinuous infections of the respiratory tractWatchful waitingEvidence/signalling of inadequate safetyEvidence/suspicion of inappropriate useVariability in clinical practiceLimited use7Caesarean sectionSpainPregnant womenLow risk birth deliveryNormal deliveryEvidence/signalling of inadequate safetyEvidence/suspicion of inappropriate useVariability in clinical practiceLimited use8Carpal tunnel releaseSpain-Carpal tunnel syndrome-Evidence/signalling of inadequate safetyEvidence/suspicion of inappropriate useVariability in clinical practiceLimited use9Diagnostic curettageSpainWomen without suspicionDiagnosis of endometrial carcinoma or hyperplasia-Evidence/suspicion of inappropriate useLow specificity and sensitivityLimited use10Routine episiotomySpainPregnant womenNormal delivery without complications-Evidence/signalling of inadequate safetyEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useLimited use11MediastinoscopyAustraliaAdults requiring lung/mediastinal lymph node biopsyLung cancerEndobronchial ultrasoundAlternative with better clinical effectiveness/safety profile availableAlternative with better cost-effectiveness availableLimited use 12HysterectomySpainWomen with metrorrhagiaHeavy menstrual bleedingendometrial ablation; levonorgestrel filled intrauterine deviceEvidence/signaling of inadequate safetyEvidence/signaling of clinical ineffectivenessEvidence/suspicion of inappropriate useLimited use13Knee arthroscopy for osteoarthritisAustraliaPatients with osteoarthritis of the kneeKnee arthroscopyPain relief and usual treatmentEvidence/signalling of clinical ineffectivenessTBD14Surgical interventions for treatment of shoulder impingementSwitzerlandPatients with chronic shoulder pain due to impingement-syndromeSurgical interventions in patients with chronic shoulder pain due to an impingement-syndromeWatchful waiting, physiotherapy, analgesicsEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useTBD15Vertebroplasty/KyphoplastySwitzerlandOsteoporosis patients with painful osteoporotic vertebral fracturesComplete disinvestment of vertebroplasty / kyphoplasty for osteoporotic vertebral fracturesConservative medical treatment; analgeticsEvidence/signaling of inadequate safetyEvidence/signaling of clinical ineffectivenessEvidence/suspicion of inappropriate useHigh geographic variation cost reduction TBD Medical Devices16Mechanical chest compression devicesUnited Kingdom ---Alternative with better clinical effectiveness/safety profile available Limited use17Antimicrobial wound dressingsAustraliaAll wound types-Non antimicrobial wound dressings; time limited use of antimicrobial dressingEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useLimited use18nCPAPSwitzerlandPatients with OSASnCPAP treatment for mild and moderate form of OSAS ( AHI: 5 – 14.9 and 15 – 30). nCPAP treatment for the severe form of OSAS (AHI > 30) is not questioned.Removable dental mouthpieces. Evidence/suspicion of inappropriate useLow patient compliance with nCPAP treatment for the mild and moderate form of OSAS which effects clinical efficacy. cost reductionTBD19Test strips for SMBGSwitzerlandNon-insulin dependent T2DM patients400 test strips/year for SMBG in non-insulin dependent T2DM patientsDiabetes care without SMBG or diabetes care with structured SMBG with reduced amount of test stripsEvidence/suspicion of inappropriate useCost reduction if better cost-effectiveness is not shownTBDDiagnostic Tests20Vitamin D testsSwitzerlandPatients suffering from signs of diseases with a suggested link to vitamin DVitamin D tests for patients suffering from diseases with a suggested link to vitamin D(Currently there is no limitation)Vitamin D supplementation without vitamin D testing; vitamin D rich diet + sun without vitamin D testingEvidence/suspicion of inappropriate use; cost reductionTBD21Vitamin B12 testsSwitzerlandPatients suffering from signs of disease with a suggested link to vitamin B12. Vitamin B12 tests for patients suffering from diseases with a suggested link to vitamin B12(Currently there is no limitation)No vitamin B12 test; vitamin B12 supplementation without a test Evidence/suspicion of inappropriate usecost reductionTBDDrug Therapies22DiacereinSpainOsteoarthritisPain killers, platelet rich growth factors, mother cellsEvidence/signalling of inadequate safety Evidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useComplete removal23Chondroitin sulphate containing drugsSpainOsteoarthritisPain killers, platelet rich growth factors, mother cellsEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useComplete removalSwitzerlandpatients with degenerative joint diseases,osteoarthritiscomplete disinvestment of chondroitin sulphate containing drugs for patients with degenerative joint diseasesStandard of care (analgetics, physiotherapie)Evidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useTBD24Olmesartan SwitzerlandPatients with essential arterial hypertensionEssential arterial hypertensionAlternative antihypertensive drugsEvidence/signalling of inadequate safetyTBD25PPISwitzerlanda) Patients with NERD which are symptom-free after 4 - 8 weeks initial acute PPI therapy; b) Patients with non-investigated GERD (no prior endoscopic investigation) which are symptom free after 4 – 8 weeks initial acute PPI therapyA continuous (daily) PPI long-term therapy for the mentioned indications is proposed to be limited to an on-demand PPI long-term therapyOn-demand therapy with PPIs (approx. on 30 – 50 % of the days per year), i.e. a PPI is only taken by the patient if symptoms occurEvidence/suspicion of inappropriate useCost reductionTBD26Parenteral iron substitutesSwitzerlandPeople with iron deficiency without anemiaLimitation of parenteral iron substitutes to patients with iron deficiency with anemiaNo treatment with iron substitutes or first line oral therapy with iron substitutes with possible switch to parenteral therapyEvidence/suspicion of inappropriate useCost reductionTBDAHI = Apnea-Hypopnea-Index; GERD = gastroesophageal reflux disease; n-CPAP = nasal continuous positive airway pressure treatment; NERD = non-erosive gastroesophageal reflux disease; OSAS = obstructive sleep apnea syndrome; PPI = proton pump inhibitor; Self-monitoring of blood glucose; T2DM = type 2 diabetes mellitus; TBD = to be determined. Supplemental Table 2: Estimated Costs of Use and Savings per Year of Disinvestment CandidateShown for health technologies and procedures with data on economic details provided by the survey respondents.No.TechnologyCountryFrequency of UseEstimated Costs of Use per Year (Euro)Estimated Cost Savings per Year (Euro)Reason(s) for Proposed DisinvestmentDecisionMedical Services or Procedures1Liver biopsyAustralia>1,000> 4 m> 2 m Alternative with better clinical effectiveness/safety profile available Complete removal2Surgical removal of pacemaker leadsAustralia~50>10 m> 5 mAlternative with better clinical effectiveness/safety profile available Alternative with better cost-effectiveness available Complete removal3Transurethral resection of the prostate Australia>5,000>10 m> 5 mAlternative with better clinical effectiveness/safety profile available Alternative with better cost-effectiveness available Limited use4MediastinoscopyAustralia>100>10 m> 5 mAlternative with better clinical effectiveness/safety profile availableAlternative with better cost-effectiveness availableLimited use 5Surgical interventions for treatment of shoulder impingementSwitzerland2,600 surgical interventions/year12 mTBDEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useTBD6Vertebroplasty/KyphoplastySwitzerlandApprox. 3000 inpatient and 300 ambulatory services per year25 mTBDEvidence/signaling of inadequate safetyEvidence/signaling of clinical ineffectivenessEvidence/suspicion of inappropriate useHigh geographic variation cost reduction is a reason TBD Medical Devices7nCPAPSwitzerland11,000 patients13.8 in 2015TBDEvidence/suspicion of inappropriate useLow patient compliance with nCPAP treatment for the mild and moderate form of OSAS which effects clinical efficacy. cost reductionTBD8Test strips for SMBGSwitzerland280'000 patients who use on average 200 test strips/patient/year45 m TBDEvidence/suspicion of inappropriate useCost reduction if better cost-effectiveness is not shownTBDDiagnostic Tests9Vitamin D testsSwitzerland940,000 tests in 2014 versus 390 000 tests in 201143 m in 2014TBDEvidence/suspicion of inappropriate use; cost reductionTBD10Vitamin B12 testsSwitzerland970,000 tests in 2015 versus 680,000 tests in 201121.5 m in 2015 TBDEvidence/suspicion of inappropriate usecost reductionTBDDrug Therapies11DiacereinSpain-0.4 m0.4 mEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useComplete removal12Chondroitin sulphate containing drugsSpain-4.5 m4.5 mEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useComplete removalSwitzerlandApprox. 200'000 patients/year25 m TBDEvidence/signalling of clinical ineffectivenessEvidence/suspicion of inappropriate useTBD13Olmesartan (monotherapy or combination therapy)Switzerland70,000 patients are treated continuously with Olmesartan products25 m TDBEvidence/signalling of inadequate safetyTBD14PPISwitzerlandApprox. 1 m GERD patients in Switzerland are prescribed continuous PPI therapy. It is assumed that 50 – 70 % of these patients are NERD patients, which may potentially benefit from an on-demand PPI therapy.~75 m – 105 mTBDEvidence/suspicion of inappropriate useCost reductionTBD15Parenteral iron substitutesSwitzerland122,000 treatment cycles/year for one product alone. Other products are on the market as well50 mTBDEvidence/suspicion of inappropriate useCost reductionTBDAHI = Apnea-Hypopnea-Index; GERD = gastroesophageal reflux disease; n-CPAP = nasal continuous positive airway pressure treatment; NERD = non-erosive gastroesophageal reflux disease; OSAS = obstructive sleep apnea syndrome; PPI = proton pump inhibitor; SMBG = Self-monitoring of blood glucose; T2DM = type 2 diabetes mellitus; TBD = to be determined. ................
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