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”

Document Type : Commentary


Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands


Low-value care is increasingly recognized as a global problem that places strain on healthcare systems and has no quick fix. Verkerk et al have identified key factors promoting low-value care on a national level, proposed strategies to address these and create a healthcare system facilitating delivery of high-value care. In this commentary, we reflect on the results of Verkerk et al and argue that uncertainty has a crucial role when it comes to reducing low-value care. This uncertainty is reflected in lack of a shared view between stakeholders, with clear criteria and thresholds on what constitutes low-value care, and as cross-cutting theme related to the key factors identified. We suggest to work on such a shared view of low-value care and – different from implementation efforts – to explicitly address uncertainty and its driving cognitive biases grounded in human decision-making psychology, to reduce low-value care.


  • epublished Author Accepted Version: March 12, 2022
  • epublished Final Version: March 15, 2022
  1. Oakes AH, Radomski TR. Reducing low-value care and improving health care value. JAMA. 2021;325(17):1715-1716. doi:1001/jama.2021.3308
  2. Mafi JN, Parchman M. Low-value care: an intractable global problem with no quick fix. BMJ Qual Saf. 2018;27(5):333-336. doi:1136/bmjqs-2017-007477
  3. van Dulmen SA, Naaktgeboren CA, Heus P, et al. Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis. BMJ Open. 2020;10(10):e040025. doi:1136/bmjopen-2020-040025
  4. Verkerk EW, Van Dulmen SA, Born K, Gupta R, Westert GP, Kool RB. Key factors that promote low-value care: views of experts from the United States, Canada, and the Netherlands. Int J Health Policy Manag. 2021. doi:34172/ijhpm.2021.53
  5. Fleuren MA, Paulussen TG, Van Dommelen P, Van Buuren S. Towards a measurement instrument for determinants of innovations. Int J Qual Health Care. 2014;26(5):501-510. doi:1093/intqhc/mzu060
  6. Wheeler SB, Spencer J, Rotter J. Toward value in health care: perspectives, priorities, and policy. N C Med J. 2018;79(1):62-65. doi:18043/ncm.79.1.62
  7. Verkerk EW, Tanke MAC, Kool RB, van Dulmen SA, Westert GP. Limit, lean or listen? A typology of low-value care that gives direction in de-implementation. Int J Qual Health Care. 2018;30(9):736-739. doi:1093/intqhc/mzy100
  8. Born KB, Levinson W. Choosing Wisely campaigns globally: a shared approach to tackling the problem of overuse in healthcare. J Gen Fam Med. 2019;20(1):9-12. doi:1002/jgf2.225
  9. Sacristán JA. How to assess the value of low-value care. BMC Health Serv Res. 2020;20(1):1000. doi:1186/s12913-020-05825-y
  10. Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311(7001):376-380. doi:1136/bmj.311.7001.376
  11. Grupe DW, Nitschke JB. Uncertainty and anticipation in anxiety: an integrated neurobiological and psychological perspective. Nat Rev Neurosci. 2013;14(7):488-501. doi:1038/nrn3524
  12. Tarrant C, Krockow EM. Antibiotic overuse: managing uncertainty and mitigating against overtreatment. BMJ Qual Saf. 2022;31(3):163-167. doi:1136/bmjqs-2021-013615
  13. Helfrich CD, Rose AJ, Hartmann CW, et al. How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: a preliminary model of unlearning and substitution. J Eval Clin Pract. 2018;24(1):198-205. doi:1111/jep.12855
  14. McDaniel CE, House SA, Ralston SL. Behavioral and psychological aspects of the physician experience with deimplementation. Pediatr Qual Saf. 2022;7(1):e524. doi:1097/pq9.0000000000000524
  15. Scott IA, Soon J, Elshaug AG, Lindner R. Countering cognitive biases in minimising low value care. Med J Aust. 2017;206(9):407-411. doi:5694/mja16.00999
  16. Patey AM, Grimshaw JM, Francis JJ. Changing behaviour, 'more or less': do implementation and de-implementation interventions include different behaviour change techniques? Implement Sci. 2021;16(1):20. doi:1186/s13012-021-01089-0
Volume 11, Issue 9
September 2022
Pages 1964-1966
  • Receive Date: 17 December 2021
  • Revise Date: 01 March 2022
  • Accept Date: 09 March 2022
  • First Publish Date: 12 March 2022