Making wise choices about low‐value health care in the COVID‐19 pandemic

Overuse of health care can cause harm to individuals and threaten the sustainability of health systems. The importance of addressing overuse is heightened by the imperative to control healthcare costs, which were growing substantially even before the COVID‐19 pandemic. Unnecessary interventions, treatments, and tests may harm patients through direct adverse effects, psychosocial impacts of labelling, and financial and practical burdens. Use of ineffective interventions, sometimes driven by commercial interests, also harms the health of the public by depleting both the staffing and financial resources needed for effective and efficient care. Higher spending on healthcare also draws resources from other societal sectors that are important to the public, including education and social care, some of which may even be more likely than health care itself to improve public health. It is important, therefore, that attention is drawn to evidence on interventions that are ineffective, and we intend to do this over the coming months in a series of Cochrane Library Special Collections.

Although these challenges were apparent before COVID‐19, the pandemic has brought even more urgency to the need for healthcare sustainability. Alongside the considerable human and ethical pressures faced by patients and healthcare workers trying to cope with the direct consequence of the virus, the reorganization of how health care is delivered, including a sharp increase in virtual health care, and new public health needs have substantially drained financial and human resources. There has also been a major impact on health care for patients, with investigations and treatments being postponed or cancelled, leading to harm because of delays in timely diagnosis and treatment. Furthermore, societal lockdowns and spending to combat COVID‐19 are leading to substantial and increasing economic challenges. These may have an even greater impact in low‐ and middle‐income countries. However, some impacts of the pandemic might also contribute to more sustainable health care by, for example, stopping unnecessary surgery and shifting more resources into public health prevention measures.

It is now more important than ever that the limited resources available for health care are used in ways that will generate the greatest net benefit for patients and be prioritized for those in greatest need. High‐value care needs to be delivered, and low‐value or inefficient care needs to be identified and safely wound back. As health systems all over the world face inevitable decisions about how to tackle health needs with depleted resources, these decisions need to be made in a transparent way, informed by reliable and robust evidence, and in keeping with principles of equity and ethics if health systems are to remain sustainable and fair.

The pandemic has driven a much‐increased public appetite for health information, and there is an opportunity to advance health literacy and knowledge by transparent, evidence‐based information that can explain and support resource allocation choices. Public accountability, trust and engagement in decision making can enable buy‐in and support for these difficult choices, both at the level of national or regional policy making and also in the decisions about the care of individuals. This requires better access to evidence about the effectiveness, or ineffectiveness, of interventions, as well as a better understanding of this evidence by those making choices about health care.

To advance sustainability, there is a need for better and accessible evidence on which medical interventions constitute low‐value care, as well as how such interventions could be safely wound back. To contribute to this work, Cochrane Sustainable Healthcare (sustainablehealthcare.cochrane.org) is identifying recent Cochrane Reviews where the certainty of the evidence is such that we can be confident that the results of the studies show that the intervention has little if any beneficial effect, or where harms outweigh the benefits. These reviews will be included in the planned series of Special Collections launched today. We are not recommending that these interventions are abandoned, but simply that decision makers take this evidence into consideration. If these interventions have already stopped or been scaled back because of the COVID‐19 pandemic, policy makers, practitioners, patients, and the public need to be made aware that it would be safer to not return to pre‐pandemic practices. While, if the interventions have continued, decision makers may wish to consider how best to de‐implement them.

The first Special Collection (De‐implementation of low‐value health care: resource prioritization in the COVID‐19 pandemic era) considers resource‐intense interventions, including some that require unnecessary healthcare visits, which have particular relevance because of the COVID‐19 pandemic. The subsequent Special Collections plan to focus on, for example, pharmaceutical interventions, which may have limited benefit or important harmful effects, interventions that the public might consider using (such as over‐the‐counter drugs), which have limited benefits or cause harm, and opportunities for deprescribing ineffective or harmful treatments that patients currently receive. Each Special Collection will be updated periodically.

Our aim with these Special Collections is two‐fold: to support decisions about de‐implementation by policy makers, healthcare workers and patients; and to form a basis for future projects and collaborations that will advance evidence‐based choices about de‐implementation. These projects will also need to address the need for research into how to achieve de‐implementation in practice, even when there is strong evidence or little or negative net‐value of an intervention to patients. Many barriers to evidence‐based de‐implementation have been identified on both systemic and individual levels, and much more research is needed to provide an evidence base for effective strategies for de‐implementation. Decisions about de‐implementation might also need more information on the interventions, populations, and outcomes that were studied than is available in a typical systematic review. Further, there might be important gaps in research questions asked, populations included, and outcomes studied and reported. To tackle these issues, a broad collaboration needs to be established within the evidence ecosystem, underpinned by better understanding of the perspectives and challenges for each of the stakeholders in the pathways between evidence and practice. Cochrane Sustainable Healthcare is therefore planning to work with relevant stakeholders, such as national Choosing Wisely campaign leaders, on various projects and reform initiatives, to ensure that Cochrane is able meet the needs of those making choices about de‐implementation of low‐value health care.

In conclusion, tackling overuse of ineffective or harmful healthcare interventions will reduce their direct harms and prevent waste. It will make health systems and other societal measures that impact on health more sustainable and more beneficial for patients, the public and societies. The COVID‐19 pandemic has underscored the need for reliable evidence to support treatment decisions and health policy, and dwindling public funding of health systems makes the need for evidence to identify and de‐implement ineffective interventions even more acute.

Feedback on this editorial and proposals for future editorials are welcome.

End Notes

Declarations of interest

MC receives funding from Cochrane for a project that provides lists of interventions that new and updated Cochrane Reviews show to be effective or ineffective.

KB has served as senior research associate since April 2021 as part of the secretariat of the Ontario COVID‐19 Science Advisory table which advises the Ontario government COVID‐19 response. KB has been co‐author on commentaries related to Choosing Wisely Canada and Choosing Wisely campaigns internationally. She is the knowledge translation lead for Choosing Wisely Canada and support for the Choosing Wisely international collaboration.

MJ has written several debate pieces on medical excess and works halftime as a general practitioner at Herrestads Healthcare Centre in Uddevalla. MJ is also Director of Cochrane Sustainable Healthcare, which is dedicated to advancing the field of evidence‐based de‐implementation.

KJJ is co‐author of a Cochrane Review included in the Special Collection related to this editorial.

EM is co‐author of a Cochrane Review included in the Special Collection related to this editorial.

JVAF has written about the topic of this editorial in medical journals, and he also works half‐time as a healthcare professional.

Provenance and peer review

This editorial was commissioned based on a proposal by the authors and was externally peer reviewed.