Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands

Document Type : Original Article


1 Department of IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands

2 Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada

3 University of California Health, Sacramento, CA, USA


Around the world, policies and interventions are used to encourage clinicians to reduce low- value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries.
We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis.
The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a ‘more is better’ culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy.

Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.



Commentaries Published on this Paper


  • Context, Culture, and the Complexity of De-Implementing Low-Value Care; Comment on “Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands”

         Abstract | PDF


  • Overview of the Drivers of Low-Value Care; Comment on “Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands”

         Abstract | PDF


  • Reducing Low-Value Care: Uncertainty as Crucial Cross-Cutting Theme; Comment on “Key Factors That Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands”

         Abstract | PDF


  • Tools to Reduce Low-Value Care: Lessons From COVID-19 Pandemic; Comment on “Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands”

         Abstract | PDF


  • Beyond Microsystem Fixes: Targeting National Drivers of Low-Value Care; Comment on “Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands”

         Abstract | PDF


  • Low-Value Care: Convergence and Challenges; Comment on “Key Factors That Promote Low-Value Care: Views From Experts From the United States, Canada, and the Netherlands”

         Abstract | PDF


Authors' Response to the Commentaries


  •  Challenges and Opportunities for Reducing Low-Value Care; A Response to Recent Commentaries

         Abstract | PDF



  1. Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world. Lancet. 2017;390(10090):156-168. doi:10.1016/s0140-6736(16)32585-5
  2. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system: estimated costs and potential for savings. JAMA. 2019;322(15):1501-1509. doi:10.1001/jama.2019.13978
  3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi:10.1377/hlthaff.27.3.759
  4. Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA. 'Choosing Wisely': a growing international campaign. BMJ Qual Saf. 2015;24(2):167-174. doi:10.1136/bmjqs-2014-003821
  5. Saini V, Lin KW. Introducing Lown Right Care: reducing overuse and underuse. Am Fam Physician. 2018;98(10):560.
  6. Costs of Care Inc. Accessed March 25, 2020.
  7. High-value Practice Alliance. Accessed March 25, 2020.
  8. Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions aimed at reducing use of low-value health services: a systematic review. Med Care Res Rev. 2017;74(5):507-550. doi:10.1177/1077558716656970
  9. Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small decline in low-value back imaging associated with the 'Choosing Wisely' campaign, 2012-14. Health Aff (Millwood). 2017;36(4):671-679. doi:10.1377/hlthaff.2016.1263
  10. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441
  11. Niven DJ, Mrklas KJ, Holodinsky JK, et al. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med. 2015;13:255. doi:10.1186/s12916-015-0488-z
  12. Bhatia RS, Dudzinski DM, Milford CE, Picard MH, Weiner RB. Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention. Echocardiography. 2014;31(8):916-923. doi:10.1111/echo.12505
  13. Henderson J, Bouck Z, Holleman R, et al. Comparison of payment changes and Choosing Wisely recommendations for use of low-value laboratory tests in the United States and Canada. JAMA Intern Med. 2020;180(4):524-531. doi:10.1001/jamainternmed.2019.7143
  14. Kerr EA, Kullgren JT, Saini SD. Choosing Wisely: how to fulfill the promise in the next 5 years. Health Aff (Millwood). 2017;36(11):2012-2018. doi:10.1377/hlthaff.2017.0953
  15. Montini T, Graham ID. "Entrenched practices and other biases": unpacking the historical, economic, professional, and social resistance to de-implementation. Implement Sci. 2015;10:24. doi:10.1186/s13012-015-0211-7
  16. Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care. Lancet. 2017;390(10090):178-190. doi:10.1016/s0140-6736(16)30947-3
  17. Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ. 2017;358:j3879. doi:10.1136/bmj.j3879
  18. Levinson W, Born K, Wolfson D. Choosing Wisely campaigns: a work in progress. JAMA. 2018;319(19):1975-1976. doi:10.1001/jama.2018.2202
  19. Colla CH, Mainor AJ. Choosing Wisely campaign: valuable for providers who knew about it, but awareness remained constant, 2014-17. Health Aff (Millwood). 2017;36(11):2005-2011. doi:10.1377/hlthaff.2017.0945
  20. Flottorp SA, Oxman AD, Krause J, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci. 2013;8:35. doi:10.1186/1748-5908-8-35
  21. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  22. Zikmund-Fisher BJ, Kullgren JT, Fagerlin A, Klamerus ML, Bernstein SJ, Kerr EA. Perceived barriers to implementing individual Choosing Wisely® recommendations in two national surveys of primary care providers. J Gen Intern Med. 2017;32(2):210-217. doi:10.1007/s11606-016-3853-5
  23. Bishop TF, Cea M, Miranda Y, et al. Academic physicians' views on low-value services and the Choosing Wisely campaign: a qualitative study. Healthc (Amst). 2017;5(1-2):17-22. doi:10.1016/j.hjdsi.2016.04.001
  24. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perceptions of Choosing Wisely and drivers of overuse. Am J Manag Care. 2016;22(5):337-343.
  25. Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970. doi:10.1371/journal.pone.0181970
  26. Elshaug AG, Rosenthal MB, Lavis JN, et al. Levers for addressing medical underuse and overuse: achieving high-value health care. Lancet. 2017;390(10090):191-202. doi:10.1016/s0140-6736(16)32586-7
  27. Colla CH. Swimming against the current--what might work to reduce low-value care? N Engl J Med. 2014;371(14):1280-1283. doi:10.1056/NEJMp1404503
  28. Mafi JN, Parchman M. Low-value care: an intractable global problem with no quick fix. BMJ Qual Saf. 2018;27(5):333-336. doi:10.1136/bmjqs-2017-007477
  29. Berwick DM. Era 3 for medicine and health care. JAMA. 2016;315(13):1329-1330. doi:10.1001/jama.2016.1509
  30. Greene J. Fee-for-service is dead. Long live fee for service? Manag Care. 2017;26(9):22-26.
  31. Coronini-Cronberg S, Bixby H, Laverty AA, Wachter RM, Millett C. English National Health Service's savings plan may have helped reduce the use of three 'low-value' procedures. Health Aff (Millwood). 2015;34(3):381-389. doi:10.1377/hlthaff.2014.0773
  32. Gaspar K, Portrait F, van der Hijden E, Koolman X. Global budget versus cost ceiling: a natural experiment in hospital payment reform in the Netherlands. Eur J Health Econ. 2020;21(1):105-114. doi:10.1007/s10198-019-01114-6
  33. van Leersum N, Bennemeer P, Otten M, Visser S, Klink A, Kremer JAM. Cure for increasing health care costs: the Bernhoven case as driver of new standards of appropriate care. Health Policy. 2019;123(3):306-311. doi:10.1016/j.healthpol.2019.01.002
  34. Chatfield SC, Volpicelli FM, Adler NM, et al. Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre. BMJ Qual Saf. 2019;28(6):449-458. doi:10.1136/bmjqs-2018-009068
  35. Gorlach I, Pham-Kanter G. Brightening up: the effect of the Physician Payment Sunshine Act on existing regulation of pharmaceutical marketing. J Law Med Ethics. 2013;41(1):315-322. doi:10.1111/jlme.12022
  36. Perlis RH, Perlis CS. Physician payments from industry are associated with greater Medicare Part D prescribing costs. PLoS One. 2016;11(5):e0155474. doi:10.1371/journal.pone.0155474
  37. Moynihan R, Bero L, Hill S, et al. Pathways to independence: towards producing and using trustworthy evidence. BMJ. 2019;367:l6576. doi:10.1136/bmj.l6576
  38. Buist DS, Chang E, Handley M, et al. Primary care clinicians' perspectives on reducing low-value care in an integrated delivery system. Perm J. 2016;20(1):41-46. doi:10.7812/tpp/15-086
  39. Sandberg EM, Bordewijk EM, Klemann D, Driessen SRC, Twijnstra ARH, Jansen FW. Medical malpractice claims in laparoscopic gynecologic surgery: a Dutch overview of 20 years. Surg Endosc. 2017;31(12):5418-5426. doi:10.1007/s00464-017-5624-8
  40. Wammes JJ. [Onnodige zorg in de Nederlandse gezondheidszorg, gezien vanuit het perspectief van de huisarts]. Celsus; 2013.
  41. Berlin L. Medical errors, malpractice, and defensive medicine: an ill-fated triad. Diagnosis (Berl). 2017;4(3):133-139. doi:10.1515/dx-2017-0007
  42. Gupta R, Moriates C. Swimming upstream: creating a culture of high-value care. Acad Med. 2017;92(5):598-601. doi:10.1097/acm.0000000000001485
  43. Sedrak MS, Patel MS, Ziemba JB, et al. Residents' self-report on why they order perceived unnecessary inpatient laboratory tests. J Hosp Med. 2016;11(12):869-872. doi:10.1002/jhm.2645
  44. Gupta R, Moriates C, Harrison JD, et al. Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation. BMJ Qual Saf. 2017;26(6):475-483. doi:10.1136/bmjqs-2016-005612
  45. Gupta R, Steers N, Moriates C, Ong M. Association between hospitalist productivity payments and high-value care culture. J Hosp Med. 2019;14(1):16-21. doi:10.12788/jhm.3084
  46. Gupta R, Steers N, Moriates C, Wali S, Braddock CH, 3rd, Ong M. High-value care culture among the future physician workforce in internal medicine. Acad Med. 2019;94(9):1347-1354. doi:10.1097/acm.0000000000002619
  47. Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ. 2004;328(7438):474-475. doi:10.1136/bmj.328.7438.474
  48. Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Aff (Millwood). 2015;34(2):239-244. doi:10.1377/hlthaff.2014.0983
  49. Schlesinger M, Grob R. Treating, fast and slow: Americans' understanding of and responses to low-value care. Milbank Q. 2017;95(1):70-116. doi:10.1111/1468-0009.12246
  50. Sypes EE, de Grood C, Whalen-Browne L, et al. Engaging patients in de-implementation interventions to reduce low-value clinical care: a systematic review and meta-analysis. BMC Med. 2020;18(1):116. doi:10.1186/s12916-020-01567-0
  51. OECD Health Statistics. OECD Health Statistics 2014. How does the Netherlands compare? 2014; Accessed September 9, 2016.
  52. Organisation for Economic Co-operation and Development (OECD). Tackling Wasteful Spending on Health. Paris: OECD Publishing; 2017.
  53. Touboul-Lundgren P, Jensen S, Drai J, Lindbæk M. Identification of cultural determinants of antibiotic use cited in primary care in Europe: a mixed research synthesis study of integrated design "Culture is all around us". BMC Public Health. 2015;15:908. doi:10.1186/s12889-015-2254-8
  54. Deschepper R, Grigoryan L, Lundborg CS, et al. Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe? BMC Health Serv Res. 2008;8:123. doi:10.1186/1472-6963-8-123
  55. Hulscher ME, Grol RP, van der Meer JW. Antibiotic prescribing in hospitals: a social and behavioural scientific approach. Lancet Infect Dis. 2010;10(3):167-175. doi:10.1016/s1473-3099(10)70027-x
  56. Goossens H, Peetermans W, Sion JP, Bossens M. ['Evidence-based' perioperative antibiotic prophylaxis policy in Belgian hospitals after a change in the reimbursement system]. Ned Tijdschr Geneeskd. 2001;145(37):1773-1777. 
  57. Friis H, Bro F, Eriksen NR, Mabeck CE, Vejlsgaard R. The effect of reimbursement on the use of antibiotics. Scand J Prim Health Care. 1993;11(4):247-251. doi:10.3109/02813439308994839
  58. Blommaert A, Marais C, Hens N, et al. Determinants of between-country differences in ambulatory antibiotic use and antibiotic resistance in Europe: a longitudinal observational study. J Antimicrob Chemother. 2014;69(2):535-547. doi:10.1093/jac/dkt377
  59. Gianino MM, Lenzi J, Bonaudo M, Fantini MP, Ricciardi W, Damiani G. Predictors and trajectories of antibiotic consumption in 22 EU countries: findings from a time series analysis (2000-2014). PLoS One. 2018;13(6):e0199436. doi:10.1371/journal.pone.0199436
Volume 11, Issue 8
August 2022
Pages 1514-1521
  • Receive Date: 11 July 2020
  • Revise Date: 27 April 2021
  • Accept Date: 30 April 2021
  • First Publish Date: 19 June 2021