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June 22, 2020

From: Rosalie Wyonch

To: Canadians concerned about healthcare

Date: June 22, 2020

Subject: Low-Value Care and COVID-19

Low-value healthcare provides little to no benefit to patients and can cause harm.

Previous research has shown that there is much low-value care in Canada. The OECD estimates that about 20 percent of health spending is directed to activities that do not add value. The COVID-19 pandemic has put significant strain on healthcare system resources across the world. Cost pressures on the health system are only going to increase, so reducing low-value care is an important part of maintaining and improving the quality of healthcare.

Patients, clinicians and the system itself are all drivers of low-value care. There is no single factor responsible for low-value care, and it has many complex drivers.

Patients can seek unnecessary treatments, or might not feel they have received adequate services if they leave an appointment “empty handed” (action bias). Clinicians might over-prescribe or order unnecessary tests and treatments due to risk aversion, both personally and for patients, with respect to meeting patients’ needs and personal fear of lawsuits. Inadequate training or outdated habits also contribute to low-value care.

Systemic factors also contribute to perpetuating low-value care. In many provinces, physician remuneration often doesn’t encourage appropriate resource stewardship. Passive mechanisms, such as default-listed items on standardized order forms, affect the number and frequency of services that physicians request. In some cases, low-value procedures might be required by existing policy or legislation for certain healthcare procedures. For example, the Public Hospitals Act in Ontario requires pathological tests for tissue removed during uncomplicated hip and knee replacement surgeries, even though research shows that it does not alter patient management or outcomes.

Part of the challenge in addressing low-value care is that it can be difficult to measure. It is easy to observe what has been ordered and with what frequency, but in many cases, determining appropriateness requires information about individual patient complexity. For many common interventions, however, a physician’s practice and ordering patterns could be compared to objective clinical standards, to other physicians’ behaviour or assessed based on patient outcomes. Administrative data can also contribute to assessments of appropriateness, for example through comparing mean abnormal results rate to volume of diagnostic test orders.

The response to COVID-19 has driven rapid and unprecedented restrictions in access and changes to the delivery of healthcare. The silver lining to this disruption is that it is a wide-scale, ongoing natural experiment that will likely change prevailing views about what is low-value and how care is prioritized. The waitlists for surgeries and other services have grown as a result of COVID-related cancellations. With constrained resources, there is a renewed focus on improving triage procedures – methods of matching highest need patients with soonest available resources. This renewed focus and the crisis itself have highlighted data and information gaps that could facilitate more efficient management of health resources.

COVID-19 has put significant strain on already scarce resources for healthcare. Before the current crisis, there were concerns about the fiscal sustainability of increases in healthcare spending. The economic consequences of the pandemic, associated restrictions and significant government spending to moderate the negative effects mean that public spending will need to be constrained in the future. Healthcare represents more than a third of provincial program spending across the country and it will not be immune from the fiscal pressure.

To maintain a high quality and accessible healthcare system, policymakers, managers and clinicians will need to evaluate the effects of the recent restrictions and ruthlessly determine value for patients. The combined pressures of the pandemic and its associated economic damage require decision-makers to address the complex drivers of low-value care. The sustainability of the healthcare system depends on it.

Rosalie Wyonch is a Policy Analyst at the C.D. Howe Institute. 

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.