LAUSR

Low‐value care threatened the sustainability of healthcare even before the COVID‐19 pandemic with up to 30% of care estimated to be wasteful—meaning it does not add value and may even be harmful to patients. The direct costs of COVID‐19, along with backlogs of delayed care, and staffing shortages, have only intensified fiscal constraints. Now more than ever, healthcare systems must find ways to better utilize finite healthcare resources if they are to be sustainable. It was one decade ago that Choosing Wisely began in the United States to reduce the use of unnecessary medical tests, treatments, and procedures (i.e., low‐value care), and has since spread to over 30 countries. To date, it has been primarily a bottom‐up campaign. The lists by professional societies were a starting point that emphasized many of the “easy wins” to reducing low‐value care, but they are by no means the largest causes of waste in the healthcare system. Most unnecessary care is intertwined with appropriate care and is much more challenging to “de‐implement.” But in some countries, like Canada, Choosing Wisely has moved from an awareness campaign to focus on system re‐design. Not surprisingly, the evidence shows that the campaign has had modest successes in reducing low‐value care, typically at single sites and involving relatively easy‐to‐eliminate tests or treatments. Table 1 lists examples of strategies shown to reduce low‐value care that can be implemented across the hierarchy of intervention effectiveness. This framework is a useful way to conceptualize quality improvement interventions where the lowest ranking is the most feasible but least effective as compared to the higher levels that are increasingly effective yet the hardest to implement. Education and training, which represents the majority of where Choosing Wisely has focused to date, are at the bottom of the hierarchy because although necessary, these are rarely sufficient in order to change longstanding practice patterns, particularly because many drivers of overuse are unrelated to a gap in knowledge. Dedicated stewardship programs are a successful scalable example for reducing unnecessary antimicrobial use because they do not focus on education alone but additionally provide other interventions such as real‐time feedback on prescribing practices. This model can be applied to other targets (e.g., antithrombotic agents, psychoactive drugs in the elderly) but it is not feasible to dedicate personnel to oversee stewardship programs for every overuse problem. Similarly, we cannot burden clinicians with concurrent performance report cards for more than a handful of targets. Overuse is baked into many of our existing processes of care. Simple changes can be implemented at the level of organizational rules and policies, such as revising order sets and other process redesigns to reduce redundant or unnecessary laboratory and radiologic investigations. Yet, the underappreciated distinction between fixed and variable costs means these process changes, often initiated to save money, generate only the illusion of substantial savings. Double‐checks and reminders such as preprocedural screening of patients for appropriateness, for example, prior to knee and hip surgery, are often effective but resource intensive. Addressing regional variations in practice and providing feedback to facilities or health regions may help to inform opportunities but making improvements at this broader system level is unlikely to occur without strong alignment with physician leadership. The results of