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Vitamin B12 and folate tests: the ongoing need to determine appropriate use and public funding

Cameron D Willis, Michael P Metz, Janet E Hiller and Adam G Elshaug
Med J Aust 2013; 198 (11): 586-588. || doi: 10.5694/mja12.11328

It’s not as simple as new for old: we need to follow a process for “disinvestment” in existing medical procedures, services and technologies

Criteria have been developed for assessing the safety, effectiveness and cost-effectiveness of new and emerging health interventions, but additional challenges exist in identifying opportunities for reducing the use of existing health technologies or procedures that are potentially overused, (cost-)ineffective or unsafe.1 Criteria have been proposed to flag technologies that might warrant further investigation under quality improvement programs.1 These criteria are: new evidence becomes available; there is geographical variation in use; variation in care between providers is present; the technology has evolved and differs markedly from the original; there exists a temporal trend in the volume of use; public interest or controversy is present; consultation with health care workers and funders raises concerns; new technology has displaced old technology; there is evidence of leakage (use beyond the restriction or indication); the technology or intervention is a “legacy item” that has never been assessed for cost-effectiveness; use is not in accordance with clinical guidelines; or the technology is nominated by clinical groups.

  • Cameron D Willis1,2
  • Michael P Metz3
  • Janet E Hiller4
  • Adam G Elshaug1,5,6

  • 1 Discipline of Public Health, School of Population Health, University of Adelaide, Adelaide, SA.
  • 2 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
  • 3 Clinpath Laboratories, Adelaide, SA.
  • 4 Faculty of Health Sciences, Australian Catholic University, Melbourne, VIC.
  • 5 Department of Health Care Policy, Harvard University, Boston, Mass, USA.
  • 6 Commonwealth Fund, New York, NY, USA.


Acknowledgements: 

The Assessing Service and Technology Use To Enhance Health (ASTUTE Health) study, within which vitamin B12 and folate blood tests are a case study, is funded by the National Health and Medical Research Council (NHMRC grant 565327). The findings and views expressed in this article are those of the authors and do not necessarily represent those of the Commonwealth Fund. Cameron Willis and Adam Elshaug hold NHMRC Fellowships (1013165 and 627061, respectively). Cameron Willis was supported by funding from the NHMRC Health Care in the Round Capacity Building Grant (565501). We acknowledge the valuable contributions made by Amber Watt, Dagmara Riitano and Heather Buchan. We also acknowledge the contributions made by the ASTUTE Health study group: Annette Braunack-Mayer, John Moss, Jackie Street, Tracy Merlin and Jonathan Karnon.

Competing interests:

Janet Hiller and Adam Elshaug are Co-Chief Investigators, Michael Metz is an Associate Investigator, and Cameron Willis is a former Senior Research Fellow of the ASTUTE Health study. Adam Elshaug and Janet Hiller contribute to the Australian Government Department of Health and Ageing’s Safety, Quality and Sustainability Forum and the Comprehensive Management Framework for the Medicare Benefits Schedule. Vitamin B12 and folate blood tests have been selected for review within that framework. Janet Hiller is a member of the Protocol Advisory Sub-Committee of the Medical Services Advisory Committee.

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