Overused and low-value: What to leave behind after COVID-19

By Sarah Garland

The COVID-19 pandemic has reshaped our health care system. Health care workers have, for the last year and a half, put time and effort into coping with the rising numbers of COVID-19 patients. Many have also dealt with a shortage of personal protective equipment and had to quickly adjust to offering care virtually. The next challenge is navigating the limit to the services our health care system will be able to offer — especially as provinces and territories work through the backlog of surgeries and screenings that were postponed because of the pandemic and deal with the increased need for mental health services and chronic disease care.

Post pandemic, as health care systems face new challenges, backlogs, and possible financial constraints, we may need to do more with less. As priorities shift to essential and necessary care, what sorts of practices can we leave behind after the pandemic? What can clinicians, hospitals, and policy experts choose not to do?

Choosing Wisely Canada is an organization focused on raising awareness about the harms of low-value interventions and their overuse in health care — interventions that offer little benefit, waste resources, and sometimes are harmful to patients. A key initiative of Choosing Wisely Canada is bringing together clinician societies, patients, and the public to develop lists of recommendations — often framed as “do not do’s.”

CADTH ― an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures — and Choosing Wisely Canada have highlighted some of their existing recommendations that could be used to inform priorities and practice in the post-COVID-19 era. The focus is on avoiding low-value care as our health care system rebounds from the COVID-19 pandemic.

Staff from Choosing Wisely Canada short-listed 45 from their more than 400 recommendations. Then a 10-member multi-disciplinary panel of clinicians, patient representatives, and health policy experts examined the list for recommendations that could address either needs caused by the pandemic or existing backlogs as our health care systems recover from COVID-19. This process resulted in the following “19 Recommendations to Reduce Low-Value Care,” which had a high level of consensus from the panel. A few of the recommendations from this list are highlighted below (a link to the full report is provided at the end of this article):

Don’t order baseline laboratory studies (complete blood count, coagulation testing, or serum biochemistry) for asymptomatic patients undergoing low-risk non-cardiac surgery.
Don’t order a knee MRI when weight-bearing X-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis as the MRI rarely adds useful information to guide diagnosis or treatment.
Don’t send the frail resident of a nursing home to the hospital unless their urgent comfort and medical needs cannot be met in their care home.
Don’t routinely transfuse red blood cells in hemodynamically stable intensive care unit patients with a hemoglobin concentration greater than 70 g/L (a threshold of 80 g/L may be considered for patients undergoing cardiac or orthopedic surgery and those with active cardiovascular disease).
Don’t send a patient for a specialist visit that requires several hours of transport if the visit can be done virtually or by a local physician.
Don’t do imaging for lower back pain unless red flags are present.
Don’t do imaging for uncomplicated headache unless red flags are present.

When the worst of the pandemic recedes, it will be important to meet the challenges ahead and focus on rebuilding our health care systems. Implementing these recommendations can help ensure high-value care after the pandemic. Health care professionals can use this list, in addition to other recommendations from Choosing Wisely Canada, to support decision-making and ensure patients receive appropriate care. Implementing these recommendations will depend on the local context and resources — this list of recommendations can be used as a guide for developing priorities based on local circumstances.

To read the full list of recommendations, and to learn more about how this list was developed, you can access the report — “Using Health Care Resources Wisely After the COVID-19 Pandemic: Recommendations to Reduce Low-Value Care” — in the 5th issue of the Canadian Journal of Health Technologies. To find out more about CADTH, visit cadth.ca, follow CADTH on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: cadth.ca/contact-us/liaison-officers.

Sarah Garland is a knowledge mobilization officer at CADTH.