Moving to a Sustainable Health System

The development of science and technology in healthcare can improve health outcomes for the population. For example, the pneumococcal vaccine can reduce pneumonia-associated mortality in children [1], and the polio vaccine might be able to eradicate the disease [2]. In turn, the development of policies focused on the social determinants of health (including poverty and education) allows a more global impact than the individual actions taken by hospitals or other health providers [3]. In recent years, the safety and sustainability of interventions in healthcare have been questioned [4], considering that it is estimated that a little more than a third of them are probably effective; 15% would be harmful or unhelpful, and up to 50% would be of unknown effectiveness [5].

Low-value care: when the harms outweigh the benefits

In recent decades, there has been a great emphasis on diagnostic and therapeutic interventions called low-value care or medical excess, defined as those that provide little or no benefit to patients–or those that may be considered definitively futile, with the potential of causing harm and incurring unnecessary costs for patients and the health system, thus wasting limited resources [6]. These practices include a broad spectrum with different combinations of benefits, harms, and costs. As an example, some expensive surgeries produce little or no benefits with accompanying serious health risks [7]. Other relatively low-cost interventions, usually "preventive," such as some cancer screenings [8], may result in harms through diagnostic cascades (procedures after the initial test), false positives, overdiagnosis (detection of diseases that would have had an indolent course if not detected) and subsequent overtreatment) [9]. These "low-value" interventions differ from "medical error" or malpractice, as they arise from expert recommendations, clinical guidelines, and public policies [10]. Still, "defensive medicine," a practice aimed at reducing the risk of malpractice litigation, contributes in part to the rise of low-value care by offering excessive diagnostic tests or therapeutic interventions that have not been proven effective [11].

The sustainability of the health system

There is evidence of widespread overuse of these ineffective health care interventions [12], enhanced by the phenomenon of medicalization, whereby some non-medical problems are defined and treated as diseases or disorders, expanding the use of low-value care [13]. The recipients of these harms are the people receiving these low-value interventions and the health system (and its subsystems). The value of costs incurred (called the cost-effectiveness ratio) and the total cost of implementing these interventions (budgetary impact) provide an idea of the magnitude of the problem [14]. Low-value care is partly responsible for the exponential increase in health expenditure relative to the gross domestic product in many countries (GDP) [15],[16], threatening the sustainability of the system and reproducing pre-existing inequities [17],[18]. In turn, they reduce the ability to finance policies to improve the social determinants of health, especially in a depressed economy and health systems in a post-pandemic future [19].

Initiatives

At the international level, some initiatives emerged to identify "low value" interventions: the platform "No Gracias" [20], Choosing Wisely [21], Less is More [22], Wiser Healthcare [23] Médicos sin Marca, and the movements of Quaternary Prevention [24]. Cochrane launched the working group Sustainable Healthcare [25] to research and intervene in areas where evidence can identify low-value care. Some of these initiatives have generated "do not do" lists that have effectively reduced low-value care in different areas of health [26].

At the regional level, some research indicates the high prevalence of low-value care in our population [27],[28],[29] and the media's role in promoting it [30]. In Argentina, the "Interspecialities Initiative" developed a list of locally drafted "do not do" recommendations informed by evidence [31], which the Ministry of Health later replicated. In turn, the National Commission for Health Technology Assessment was created, focused on the evidence-based assessment of health technologies [32]. In Chile, the Ministry of Health has a Department of Health Technology Assessment in Health and Evidence-based Health Care that uses the GRADE methodology to formulate recommendations during the development of all ministerial clinical practice guidelines [33]. The group Doctors Without Brand ("Médicos sin Marca") also mentions the importance of overdiagnosis as a form of iatrogenesis related to recommendations that are not supported by scientific evidence [34].

Public policies and lines of action

Considering the difficulty of de-implementing ineffective interventions that are already implemented due to resistance at all levels, it is of the utmost importance that decision-makers identify strategies to reduce the harms of 'low-value' interventions and implement efficient and equitable resource allocation in health. These strategies should be informed by the best available evidence, focusing on the sustainability of the health system and broad participation of the community considering their needs, values ​​, and preferences. The interaction of the multiple sectors of the health system--typically fragmented--and not always well coordinated in Latin America, is also essential.

We propose the following lines of work to articulate public policies with specific programs and incentives to achieve a sustainable health system.

a. Research: To carry out research studies to identify "low value" practices and strategies of de-implementation and develop guidelines for high-quality clinical practice, focusing on the sustainability of the health system.
b. Education and training: Include, in the undergraduate, graduate, and continuing education curricula of the health disciplines, contents related to potential harms of "low value" interventions and the implications for resource use and equity of its implementation. Considering the thousands of articles published every day, training professionals must acquire the ability to discriminate between good-quality evidence and critical analysis concerning low-value interventions.
c. Health systems management: To implement coverage policies that consider the potential harm to people and the sustainability of the subsystems and effectors of the health system and promote a healthy relationship between patients and health professionals, mitigating the excesses caused by "defensive medicine.
d. Intersectoral Programs: To collaborate with the media to avoid the medicalization or promotion of "low-value" practices that are not supported by rigorous evidence. Link health policies with the actions of other government portfolios with responsibility for the social determinants of health.

Conclusions

Avoiding "low-value" interventions would improve the sustainability of the healthcare system, but it largely depends on the acceptability and support of public bodies, healthcare professionals, and patients. Decision-making depends on many factors where evidence is not always the main one, and new public policies are urgently required to articulate it with the interests at stake. These could result in substantial improvements in the economy, and above all, in the health of the population.

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