What influences the outcome of active disinvestment processes in healthcare? A qualitative interview study on five recent cases of active disinvestment

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

New respondents were included for each case until informational redundancy/data saturation was reached for the case, all eligible actors for the case were interviewed, or there were no eligible actors left willing to participate.

“New respondents were included for each case until 1) no new information regarding the disinvestment process of the case emerged from the interviews (i.e. informational redundancy/data saturation was reached for the case [27]), 2) all eligible actors for the case were interviewed (i.e. no other actors were involved), or 3) there were no eligible actors left who were willing to participate.”

• cites [27] Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–907. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Haas et al. and Robinson et al. describe that there is a lack of financial incentives for healthcare providers to engage in disinvestment.

“Haas et al. and Robinson et al. describe that there is a lack of financial incentives for healthcare providers to engage in disinvestment [24, 39].”

• cites [24] Robinson S, Williams I, Dickinson H, Freeman T, Rumbold B. Priority-setting and rationing in healthcare: evidence from the English experience. Soc Sci Med. 2012;75(12):2386–93. https://doi.org/10.1016/j.socscimed.2012.09.014. sourceNot checked — no full text of the source
• cites [39] Haas M, Hall J, Viney R, Gallego G. Breaking up is hard to do: why disinvestment in medical technology is harder than investment. Aust Health Rev. 2012;36(2):148–52. https://doi.org/10.1071/AH11032. sourceSupported

Classified as probably not a substantial claim.

In the Netherlands, conditionally reimbursed interventions are reassessed after a predetermined time, usually 4 years, using findings from additional research, which may result in a disinvestment decision.

“After a predetermined time, usually 4 years, the reimbursement of the intervention will be reassessed using the findings from this additional research, which may result in a disinvestment decision [19, 20].”

• cites [19] Schelleman H. Voorwaardelijke toelating tot het basispakket 2019. Zorginstituut Nederland; 2018. Contract No.: 2017033718.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [20] Makady A, van Veelen A, de Boer A, Hillege H, Klungel OH, Goettsch W. Implementing managed entry agreements in practice: the Dutch reality check. Health Policy. 2019;123(3):267–74. https://doi.org/10.1016/j.healthpol.2018.09.016. sourcePartly supported

  The Introduction describes a planned four-year reassessment of conditionally financed hospital drugs using outcomes research, and section 3.3.3 reports advice to discontinue reimbursement for 2 of 12 drugs. But the Discussion says only one drug completed the procedure within the envisioned four years. Thus the paper supports four years as the planned interval, not as the usual interval in practice; it also concerns hospital drugs rather than conditionally reimbursed interventions generally. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim. May combine two claims.

International literature describes active disinvestment as a very difficult process, hampered by contextual aspects such as political barriers, a lack of dedicated resources, and disinvestment being considered counter-cultural.

“In the international literature, active disinvestment has been described as a very difficult process [21], hampered by contextual aspects such as political barriers [22, 23], a lack of dedicated resources [22], and disinvestment being considered counter-cultural [24].”

• cites [21] MacKean G, Noseworthy T, Elshaug AG, Leggett L, Littlejohns P, Berezanski J, et al. Health technology reassessment: the art of the possible. Int J Technol Assess Health Care. 2013;29(4):418–23. https://doi.org/10.1017/S0266462313000494. sourceSupported
• cites [22] Leggett L, Mackean G, Noseworthy TW, Sutherland L, Clement F. Current status of health technology reassessment of non-drug technologies: survey and key informant interviews. Health Res Pol Syst. 2012;10(1):38. https://doi.org/10.1186/1478-4505-10-38. sourceSupported
• cites [23] Polisena J, Trunk G, Gutierrez-Ibarluzea I, Joppi R. Disinvestment activities and candidates in the health technology assessment community: an online survey. Int J Technol Assess Health Care. 2019;35(3):189–94. https://doi.org/10.1017/S0266462319000229. sourceSupported
• cites [24] Robinson S, Williams I, Dickinson H, Freeman T, Rumbold B. Priority-setting and rationing in healthcare: evidence from the English experience. Soc Sci Med. 2012;75(12):2386–93. https://doi.org/10.1016/j.socscimed.2012.09.014. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

van Egmond et al. found that financial incentives influence the de-implementation of low-value care by healthcare providers.

“van Egmond et al. found that financial incentives influence the de-implementation of low-value care by healthcare providers [38].”

• cites [38] van Egmond S, Wakkee M, van Rengen A, Bastiaens MT, Nijsten T, Lugtenberg M. Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study. Br J Dermatol. 2019;180(6):1420–9. https://doi.org/10.1111/bjd.17594. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Previous studies have described that support, especially from clinical leaders and the general public, is essential for the success of the disinvestment process.

“support, especially from clinical leaders, but from the general public as well, was found to be essential for the success of the disinvestment process [6, 33, 34].”

• cites [6] Daniels T, Williams I, Robinson S, Spence K. Tackling disinvestment in health care services: the views of resource allocators in the English NHS. J Health Organ Manag. 2013;27(6):762–80. https://doi.org/10.1108/JHOM-11-2012-0225. sourceNot checked — no full text of the source
• cites [33] Hodgetts K, Elshaug AG, Hiller JE. What counts and how to count it: physicians’ constructions of evidence in a disinvestment context. Soc Sci Med. 2012;75(12):2191–9. https://doi.org/10.1016/j.socscimed.2012.08.016. sourcePartly supported

  The Conclusion (page not provided) says physicians have a pivotal role in implementing policy outcomes and that facilitating their buy-in is important. The Introduction links community participation to policy legitimacy and public ownership, but the paper does not say that support from clinical leaders specifically, or from the general public, is essential for successful disinvestment. (LLM, conf=0.86)

  Experimental — accuracy not yet measured
• cites [34] Garpenby P. Formal priority setting in health care: the Swedish experience. J Health Organization Manag. 2016;30(6):891–907. https://doi.org/10.1108/JHOM-09-2014-0150. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Previous studies have described that broad stakeholder engagement is considered essential for the success of disinvestment.

“broad stakeholder engagement is considered essential for the success of disinvestment”

• cites [17] Mayer J, Nachtnebel A. Disinvesting from ineffective technologies: lessons learned from current programs. Int J Technol Assess Health Care. 2015;31(6):355–62. https://doi.org/10.1017/S0266462315000641. sourceNot checked — no full text of the source
• cites [22] Leggett L, Mackean G, Noseworthy TW, Sutherland L, Clement F. Current status of health technology reassessment of non-drug technologies: survey and key informant interviews. Health Res Pol Syst. 2012;10(1):38. https://doi.org/10.1186/1478-4505-10-38. sourceSupported
• cites [24] Robinson S, Williams I, Dickinson H, Freeman T, Rumbold B. Priority-setting and rationing in healthcare: evidence from the English experience. Soc Sci Med. 2012;75(12):2386–93. https://doi.org/10.1016/j.socscimed.2012.09.014. sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

It has been suggested that qualitative studies are needed to obtain more insight into the difficult process of active disinvestment.

“Furthermore, it has been suggested that, in order to obtain more insight into this difficult process, qualitative studies are needed [23].”

• cites [23] Polisena J, Trunk G, Gutierrez-Ibarluzea I, Joppi R. Disinvestment activities and candidates in the health technology assessment community: an online survey. Int J Technol Assess Health Care. 2019;35(3):189–94. https://doi.org/10.1017/S0266462319000229. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Previous studies have described that obtaining support for disinvestment is very difficult because stakeholders often lack the will to support disinvestment due to limited perceived value and resistance to losing therapy options.

“it has also been described in previous studies that obtaining support for disinvestment is very difficult as stakeholders often lack the will to support disinvestment because of limited perceived value of disinvestment, which may take some time to realize, and their resistance to immediately “losing” therapy options [12, 35].”

• cites [12] Parkinson B, Sermet C, Clement F, Crausaz S, Godman B, Garner S, et al. Disinvestment and value-based purchasing strategies for pharmaceuticals: an international review. Pharmacoeconomics. 2015;33(9):905–24. https://doi.org/10.1007/s40273-015-0293-8. sourceSupported
• cites [35] Maloney MA, Schwartz L, O'Reilly D, Levine M. Drug disinvestment frameworks: components, challenges, and solutions. Int J Technol Assess Health Care. 2017;33(2):261–9. https://doi.org/10.1017/S0266462317000277. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Previous studies have described that it is considered very difficult to sufficiently organize broad stakeholder engagement.

“it is considered very difficult to sufficiently organize this [17, 22, 24].”

• cites [17] Mayer J, Nachtnebel A. Disinvesting from ineffective technologies: lessons learned from current programs. Int J Technol Assess Health Care. 2015;31(6):355–62. https://doi.org/10.1017/S0266462315000641. sourceNot checked — no full text of the source
• cites [22] Leggett L, Mackean G, Noseworthy TW, Sutherland L, Clement F. Current status of health technology reassessment of non-drug technologies: survey and key informant interviews. Health Res Pol Syst. 2012;10(1):38. https://doi.org/10.1186/1478-4505-10-38. sourcePartly supported

  The Results (Key informant interviews results; page unavailable) identify difficulty communicating with varied audiences as an implementation barrier. The Discussion (page unavailable) recommends engaging stakeholders as extensively as resources allow. These passages support practical constraints on broad engagement, but do not say that organizing it is considered very difficult. (LLM, conf=0.76)

  Experimental — accuracy not yet measured
• cites [24] Robinson S, Williams I, Dickinson H, Freeman T, Rumbold B. Priority-setting and rationing in healthcare: evidence from the English experience. Soc Sci Med. 2012;75(12):2386–93. https://doi.org/10.1016/j.socscimed.2012.09.014. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Conditional reimbursement has been described as creating a wedge effect, i.e. giving suppliers a "foot in the door" while creating challenges for decision-makers when the reversal of (conditional) reimbursement is warranted.

“conditional reimbursement has also been described as creating a wedge effect, i.e. giving suppliers a “foot in the door” while creating challenges for decision-makers when the reversal of (conditional) reimbursement is warranted [12].”

• cites [12] Parkinson B, Sermet C, Clement F, Crausaz S, Godman B, Garner S, et al. Disinvestment and value-based purchasing strategies for pharmaceuticals: an international review. Pharmacoeconomics. 2015;33(9):905–24. https://doi.org/10.1007/s40273-015-0293-8. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Conditional reimbursement has been proposed as a policy-tool to delay the final reimbursement decision, decreasing the uncertainty on the (cost-)effectiveness and/or budget-impact of new interventions, while making these interventions available to patients at an early stage.

“It has been proposed as a policy-tool to delay the final reimbursement decision, decreasing the uncertainty on the (cost-)effectiveness and/or budget-impact of new interventions, while making these interventions available to patients at an early stage [42, 43].”

• cites [42] van de Wetering EJ, van Exel NJA, Brouwer WBF. The challenge of conditional reimbursement: stopping reimbursement can be more difficult than not starting in the first place! Value Health. 2017;20(1):118–25. https://doi.org/10.1016/j.jval.2016.09.001. sourceSupported
• cites [43] Makady A, van Acker S, Nijmeijer H, de Boer A, Hillege H, Klungel OH, et al. Conditional financing of drugs in the Netherlands: past, present, and future—results from stakeholder interviews. Value Health. 2019;22(4):399–407. https://doi.org/10.1016/j.jval.2018.11.016. sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

Disinvestment processes are often context-specific.

“As disinvestment processes are often context-specific [21]”

• cites [21] MacKean G, Noseworthy T, Elshaug AG, Leggett L, Littlejohns P, Berezanski J, et al. Health technology reassessment: the art of the possible. Int J Technol Assess Health Care. 2013;29(4):418–23. https://doi.org/10.1017/S0266462313000494. sourcePartly supported

  The Results section, under “Moving Forward with Health Technology Reassessment,” says processes ought to be context-specific and may require local adaptation. It is discussing health technology reassessment (HTR) processes, however, and the Abstract distinguishes HTR from disinvestment. The passage therefore supports the general point about context but does not directly establish that disinvestment processes are often context-specific. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

May combine two claims.

Respondents described that the degree of support influenced the actions undertaken and, subsequently, the amount of pressure exerted.

“Respondents described that for them, as well as for other actors, the degree of support influenced the actions undertaken, and, subsequently, the amount of pressure exerted.”

May combine two claims.

In case A, where respondents suggested policymakers were in favor of disinvestment, the focus was mainly on whether the treatment was evidence-based; in case E, where policymakers described they were not in favor of disinvestment, more considerations than strictly related to the four package criteria were taken into account.

“in case A, where respondents suggested policymakers were in favor of disinvestment, the focus was mainly on whether the treatment was evidence-based, while in case E, where policymakers described they were not in favor of disinvestment, more considerations than strictly related to the four package criteria were taken into account”

May combine two claims.

We observed differences between cases in respondents' descriptions of the criteria that were used in the disinvestment process, how these criteria were interpreted, and how these criteria were weighted against one another.

“We observed differences between cases in respondents’ descriptions of the criteria that were used in the disinvestment process, how these criteria were interpreted, and how these criteria were weighted against one another.”

May combine two claims.

From comparison of interview data, the pressure exerted had a large effect on the outcome: limited pressure was exerted in cases that were actually disinvested, while much pressure was exerted in cases for which reimbursement was maintained.

“From a comparison of the interview data from the studied cases, we found that the pressure exerted had a large effect on the outcome of the disinvestment process: limited pressure was exerted in the cases that were actually disinvested, while much pressure was exerted in the cases for which reimbursement was maintained.”

May combine two claims.

By comparing interview data, cases where healthcare providers successfully exerted pressure against disinvestment were not-disinvested, while cases where healthcare providers did not exert pressure or were unsuccessful in exerting pressure were disinvested.

“By comparing the interview data from the studied cases, we found that the cases where healthcare providers successfully exerted pressure against disinvestment were not-disinvested, while cases where healthcare providers did not exert pressure or were unsuccessful in exerting pressure were disinvested.”

May combine two claims.

In this study, the engagement of patients was difficult, especially in cases where the patient group was in a vulnerable situation and, because of this, poorly organized.

“we found that the engagement of patients was difficult, especially in cases where the patient group was in a vulnerable situation and, because of this, poorly organized.”

May combine two claims.

According to respondents, whether healthcare providers were successful in exerting pressure depended on their willingness to exert pressure (level of support, role fit, financial interests) and their possibility to exert pressure (awareness, opportunities).

“According to respondents, whether healthcare providers were successful in exerting pressure depended on 1) their willingness to exert pressure, subject to a) their level of support for disinvestment of the case, b) whether they feel it fits their role (e.g. whether they feel they have an advisory role which does not comply with exerting pressure) and c) their (financial) interests”

• Also stated in: § Theme 1: support for active disinvestment and pressure exerted · plain

  “and 2) the possibility they had to exert pressure, subject to a) their awareness on how to exert pressure and b) the opportunities provided to them to do so.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In total, 37 interviews with 37 respondents and an average duration of 53 min were conducted between January and December 2018.

“In total, 37 interviews with 37 respondents and an average duration of 53 min were conducted between January and December 2018.”

May combine two claims.

We observed large differences between cases in the opportunity respondents were provided to be involved in the policy process, which seemed to depend on the support from governmental institutions for the case at hand.

“We observed large differences between cases in the opportunity respondents were provided to be involved in the policy process, which seemed to depend on the support from governmental institutions for the case at hand.”

May combine two claims.

Respondents from all cases described that the degree of support for disinvestment was related to actors' views on the case and in some cases to the attention for and framing of the case in the media.

“Respondents from all cases described that the degree of support for disinvestment was related to actors’ views on the case (i.e. health problem and intervention/service concerned), and in some cases to the attention for and framing of the case in the media.”

May combine two claims.

Policymakers describe that they consider disinvestment much more difficult than not to start reimbursement in the first place, especially if disinvestment results in current patients having to stop their treatment or switch to another treatment.

“This is illustrated by the quotes from policymakers below in which they describe that they consider disinvestment much more difficult than not to start reimbursement in the first place, especially if disinvestment results in current patients having to stop their treatment or switch to another treatment.”

May combine two claims.

A poor organization of patient groups may make it difficult for patients to exert pressure, which may contribute to successful disinvestment.

“A poor organization of patient groups may make it difficult for patients to exert pressure, which may contribute to successful disinvestment.”

Classified as probably not a substantial claim. May combine two claims.

Because of this, according to respondents, patients were poorly organized, which made it difficult to get a large group of patients to exert pressure against disinvestment.

“Because of this, according to respondents, patients were poorly organized, which made it difficult to get a large group of patients to exert pressure against disinvestment, as is illustrated by the quote below.”

May combine two claims.

Once the Minister decides on reimbursement, health insurers subsequently implement these reimbursement decisions, and patients/healthcare providers are both consulted in reimbursement decisions and in the implementation of these decisions.

“Once the Minister decides on reimbursement, health insurers subsequently implement these reimbursement decisions, and patients/healthcare providers are both consulted in reimbursement decisions and in the implementation of these decisions.”

Classified as probably not a substantial claim.

Using a qualitative approach enabled the study to obtain in-depth insight into the factors that influence disinvestment processes and their outcomes.

“we have used a qualitative approach which enabled us to obtain in-depth insight into the factors that influence disinvestment processes and their outcomes.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In four out of five cases, either data saturation was reached and/or all eligible actors were interviewed.

“In four out of five cases, either data saturation was reached and/or all eligible actors were interviewed.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A subset of 15 interviews was also coded by JvdR to assess the reliability of data analysis.

“A subset of 15 interviews was also coded by JvdR to assess the reliability of data analysis [32].”

• cites [32] Mays N, Pope C. Qualitative research: rigour and qualitative research. BMJ. 1995;311(6997):109–12. https://doi.org/10.1136/bmj.311.6997.109. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

In the quit smoking program case, not all eligible actors were interviewed as we did not succeed to include a politician who was involved.

“In the quit smoking program case, not all eligible actors were interviewed as we did not succeed to include a politician who was involved.”

May combine two claims.

The Minister has taken several decisions to exclude specific interventions from the basic benefits package, indicating that the assumption that existing interventions not meeting the package criteria will automatically be passively disinvested may not always hold.

“However, in recent years, the Minister has taken several decisions to exclude specific interventions from the basic benefits package, indicating that the assumption that existing interventions not meeting the package criteria anymore will automatically be (passively) disinvested may not always hold [17, 18].”

• cites [17] Mayer J, Nachtnebel A. Disinvesting from ineffective technologies: lessons learned from current programs. Int J Technol Assess Health Care. 2015;31(6):355–62. https://doi.org/10.1017/S0266462315000641. sourceNot checked — no full text of the source
• cites [18] van Dulmen S, Heus P, Kool T, Verkerk E. Doen of laten in de gezondheidszorg. Een onderzoek naar de mogelijkheden van terugdringen van niet-gepaste zorg. [To do or not to do in healthcare. A study after the possibilities to reduce low-value care.]. Nijmegen: Scientific Center for Quality of Healthcare (IQ healthcare); 2019.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• AssumptionThe authors state this as an assumption: For interventions covered by the basic benefits package, if they do not meet the package criteria anymore, they will no longer be delivered by healthcare providers (passive disinvestment), so explicit exclusion is not necessary.

May combine two claims.

A sample (40%) of the interview transcripts was double coded, and the matrices were checked for recurring themes by three researchers, ensuring the reliability of data analysis.

“as a sample (40%) of the interview transcripts was double coded, and the matrices were checked for recurring themes by three researchers, we ensured the reliability of data analysis [32].”

• cites [32] Mays N, Pope C. Qualitative research: rigour and qualitative research. BMJ. 1995;311(6997):109–12. https://doi.org/10.1136/bmj.311.6997.109. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

We did not aim to reach saturation with regards to the perspectives of the different actor groups on disinvestment.

“We did not aim to reach saturation with regards to the perspectives of the different actor groups on disinvestment.”

Classified as probably not a substantial claim.

Interviewing different actors enabled the study to look at the disinvestment process from different perspectives, in addition to the formal perspective of policymakers obtained from policy reports.

“through interviewing different actors, we were able to look at the disinvestment process from different perspectives, in addition to the formal perspective of policymakers obtained from policy reports.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

This is the first study to describe the agenda-setting, policy-formulation and decision-making stages of the active disinvestment process, and to explore aspects influencing its outcome.

“To our knowledge, this is the first study to describe the agenda-setting, policy-formulation and decision-making stages of the active disinvestment process, and to explore aspects influencing its outcome.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Including multiple respondents for each case was used to overcome the limitation of information omission.

“We tried to overcome this limitation by including multiple respondents for each case.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Quotes used in the paper were approved by respondents, without them having the possibility to change anything regarding the findings.

“Quotes that were used in this paper were approved by respondents, without them having the possibility to change anything regarding the findings.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Respondents may have (intentionally or unintentionally) left some relevant information out.

“it may be that respondents (intentionally or unintentionally) left some relevant information out.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Written informed consent was obtained at the start of the interview.

“Written informed consent was obtained at the start of the interview.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Older cases may have been more prone to information omission because respondents may have had trouble remembering the relevant information.

“the older cases may have also been more prone to information omission because respondents may have had trouble remembering the relevant information.”

May combine two claims.

Active disinvestment processes in the Netherlands have differed in outcome: some attempts resulted in actual disinvestment, while others were terminated, implying unsuccessful disinvestment.

“Active disinvestment processes in the Netherlands have clearly differed in their outcome. Some attempts at disinvestment resulted in actual disinvestment. Other attempts were terminated at some point, implying unsuccessful disinvestment.”

Classified as probably not a substantial claim.

Interviewing many different actors who perceived the disinvestment process from different perspectives enabled the study to obtain a comprehensive view of the disinvestment processes studied.

“by interviewing many different actors who have perceived the disinvestment process from different perspectives, we were able to obtain a comprehensive view of the disinvestment processes studied.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study may have missed aspects determining the outcome of the disinvestment process that may have been more pronounced in the non-selected cases.

“we may have missed aspects determining the outcome of the disinvestment process that may have been more pronounced in the non-selected cases.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The research project was assessed by the Centre for Clinical Expertise (CCE) at the RIVM, which concluded that it is exempted from further review by a medical ethics committee.

“This research project has been assessed by the Centre for Clinical Expertise (CCE) at the RIVM. The CCE concluded that the research project is exempted from further review by a medical ethics committee as it does not fulfill the specific conditions as stated in the Dutch Medical Research Involving Human Subjects Act (WMO; Wet Medisch-wetenschappelijk Onderzoek met mensen).”

Classified as probably not a substantial claim.

Using a qualitative approach enabled the study to collect information that has not been included in the formal policy reports written about these cases.

“and to collect information that has not been included in the formal policy reports written about these cases.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A lack of support from decision-makers has been described as a barrier to the implementation of disinvestment.

“a lack of support from decision-makers has been described as a barrier to the implementation of disinvestment [17].”

• cites [17] Mayer J, Nachtnebel A. Disinvesting from ineffective technologies: lessons learned from current programs. Int J Technol Assess Health Care. 2015;31(6):355–62. https://doi.org/10.1017/S0266462315000641. sourceNot checked — no full text of the source

May combine two claims.

Contextual factors as well as the possibility to relieve the consequences of disinvestment for current patients are important determinants of the outcome of active disinvestment processes.

“Contextual factors as well as the possibility to relieve the consequences of disinvestment for current patients are important determinants of the outcome of active disinvestment processes.”

Classified as probably not a substantial claim.

Consistency in the rationale underlying decisions has been described as an important requirement for decision-making to be considered fair.

“consistency in the rationale underlying decisions has been described as an important requirement for decision-making to be considered fair [40].”

• cites [40] Daniels N, Sabin J. Setting limits fairly - learning to share resources for health. 2nd ed. New York: Oxford University Press, Inc.; 2008. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

A review from 2008 found healthcare providers and administrators to be most influential in reimbursement decisions for new medicines.

“A review from 2008 focusing on reimbursement decisions for new medicines also found healthcare providers and administrators (i.e. policymakers) to be most influential in reimbursement decisions [36]”

• cites [36] Vuorenkoski L, Toiviainen H, Hemminki E. Decision-making in priority setting for medicines—a review of empirical studies. Health Pol. 2008;86(1):1–9. https://doi.org/10.1016/j.healthpol.2007.09.007. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The disinvestment process of the studied cases took place several years ago, and it may have been perceived as a closed chapter by respondents, making elaborating on the cases less sensitive and reflecting on it easier.

“as the disinvestment process of the studied cases took place several years ago, it may have been perceived as a closed chapter by respondents, making elaborating on the cases less sensitive and reflecting on it easier.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

No conflicting information was obtained from the interviews with the different respondents, indicating that there are no clear signs of information omission.

“No conflicting information was obtained from the interviews with the different respondents, indicating that there are no clear signs of information omission.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the cases where saturation was reached, no new information on the disinvestment process of the case was obtained from the last interviews conducted.

“In the cases where saturation was reached, no new information on the disinvestment process of the case was obtained from the last interviews conducted.”

May combine two claims.

This indicates that the possibility to take such mitigating measures impacts the support for disinvestment from actors and, subsequently, the outcome of the disinvestment process.

“This indicates that the possibility to take such mitigating measures impacts the support for disinvestment from actors and, subsequently, the outcome of the disinvestment process.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Case D still appeared to be sensitive to respondents, indicating that it may be more prone to information omission.

“Especially one of the five cases studied (i.e. case D) still appeared to be sensitive to respondents, indicating that it may be more prone to information omission.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Respondents were explained that only the research team would have access to the audio recordings and transcripts, and that they would handle this information confidentially.

“Respondents were explained that only the research team would have access to the audio recordings and transcripts of their interviews, and that they would handle this information confidentially.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The perspectives of all the different actors were of added value and treated equally, complementing each other in the reconstruction of the disinvestment processes.

“The perspectives of all the different actors were of added value and treated equally, complementing each other in the reconstruction of the disinvestment processes.”

May combine two claims.

In the Dutch health insurance system, two groups of policy makers advise the Minister on reimbursement: ZiNL is involved with reimbursement aspects with regards to content, while policy makers of the Ministry itself both focus at the content and context of reimbursement.

“In the Dutch health insurance system, two groups of policy makers advise the Minister on reimbursement (policy formulation): ZiNL is involved with reimbursement aspects with regards to content, while policy makers of the Ministry itself both focus at the content and context of reimbursement.”

May combine two claims.

Every actor can be involved in agenda-setting, although policymakers often have the most distinct role in this phase.

“Every actor can be involved in agenda-setting, although policymakers often have the most distinct role in this phase.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Within the subset of 15 interviews, there was sufficient consensus between both coders on the text fragments coded and the codes used; therefore, double coding of the remaining interviews was deemed unnecessary.

“Within this subset of 15 interviews, there was sufficient consensus between both coders on the text fragments coded and the codes used to code these fragments. Therefore, double coding of the remaining interviews was deemed unnecessary (i.e. remaining interviews were only coded by AR).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The final themes were checked for plausibility and approved by the second coder based on his/her knowledge of the data from coding a subset of the interviews.

“The final themes were checked for plausibility and approved by the second coder based on his/her knowledge of the data from coding a subset of the interviews.”

Classified as probably not a substantial claim.

Using a qualitative approach enabled the study to study the reasoning behind choices in the active disinvestment process of the five cases in-depth.

“By using a qualitative approach, we were able to study the reasoning behind the choices made in the active disinvestment process of the five cases studied in-depth”

Probably not a substantial claim: may not pass S3 (load-bearing).

Showing respondents a timeline displaying policy reports and the reimbursement status appeared to be helpful for respondents in remembering the disinvestment process.

“In the interviews, this timeline appeared to be helpful for respondents in remembering the disinvestment process.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

Actors may have a different tendency to stick to these roles in other healthcare systems.

“actors may have a different tendency to stick to these roles.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

As politicians played a major role in this case, it would have been informative to interview a politician.

“As politicians played a major role in this case, it would have been informative to interview a politician.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

In other healthcare systems, the roles may be differently divided between the different actors than is the case in the Dutch healthcare system.

“in other healthcare systems, the roles may be differently divided between the different actors than is the case in the Dutch healthcare system.”

Classified as probably not a substantial claim.

As the intervention has already been provided to patients, reversal of reimbursement implies the withdrawal of treatment.

“As the intervention has already been provided to patients, reversal of reimbursement implies the withdrawal of treatment”

Probably not a substantial claim: may not pass S3 (load-bearing).

Conditional reimbursement has the advantage that support for disinvestment can be ensured before starting reimbursement.

“conditional reimbursement has the advantage that support for disinvestment can be ensured before starting reimbursement.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

This may affect the importance of this aspect for the outcome of disinvestment processes in other healthcare systems.

“This may affect the importance of this aspect for the outcome of disinvestment processes in other healthcare systems.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Almost all approached actors were willing to participate in the current study.

“In our current study, almost all approached actors were willing to participate.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In the quit smoking program case, the study was not able to interview all eligible actors because it did not succeed in including a politician who was involved in this case.

“in the quit smoking program case we were not able to interview all eligible actors because we did not succeed in including a politician who was involved in this case.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The large willingness to participate may have been caused by the fact that the disinvestment processes of the cases took place several years ago.

“We believe that this large willingness to participate may have been caused by the fact that the disinvestment processes of the cases took place several years ago.”

Probably not a substantial claim: may not pass S2 (checkable).

The specific nature of conditional reimbursement processes provides policymakers with opportunities to address the aspects influencing the likelihood of an active disinvestment process to result in a disinvestment decision, as identified in our study.

“the specific nature of conditional reimbursement processes, provides policymakers with opportunities to address the aspects influencing the likelihood of an active disinvestment process to result in a disinvestment decision, as identified in our study.”