Engaging clinicians in evidence-based disinvestment: Role and perceptions of evidence

Objectives: The aim of this study was to determine how evidence from systematic review (SR) is perceived and negotiated by expert stakeholders in considering a technology for potential disinvestment. Methods: An evidence-informed stakeholder engagement examined results from a diagnostic accuracy SR of vitamin B-12 and folate tests. Pathologists deliberated around the SR findings to generate an informed contribution to future policy for the funding of B-12 and folate tests. Deliberations were transcribed and subject to qualitative analysis. Results: Pathologists did not engage with findings from the SR in depth; rather they sought to contest the terms of the problem driving the review and attempted to reframe it. Pathologists questioned the usefulness of SR outcomes given the variable definitions of B-12 deficiency and deferred addressing disinvestment options specifically pertaining to B-12 testing. However, folate testing was proffered as a potential disinvestment candidate, based upon pathologists' definition of 'appropriate' evidence beyond the bounds of the SR. Conclusions: The value of SR to informing disinvestment deliberations by expert stakeholders may be a function of timing as well as content. Engagement of stakeholders in co-produced evidence may be required at two levels: (i) Early in the synthesis phase to help shape the SR and harmonize expert views with the available evidence (including gaps); (ii) Collaboration in primary research to fill evidence-gaps thus supporting evidence-based disinvestment. Without this, information asymmetry between clinically engaged experts and decision makers may preclude the collaborative, informed, and technical discussions required to generate productive policy change