Identifying and prioritizing lower value services from Dutch specialist guidelines and a comparison with the UK do-not-do list

The term 'lower value services' concerns healthcare that is of little or no value to the patient and consequently should not be provided routinely, or not be provided at all. De-adoption of lower value care may occur through explicit recommendations in clinical guidelines. The present study aimed to generate a comprehensive list of lower value services for the Netherlands that assesses the type of care and associated medical conditions. The list was compared with the NICE do-not-do list (United Kingdom). Finally, the feasibility of prioritizing the list was studied to identify conditions where de-adoption is warranted.


Dutch clinical guidelines (published from 2010 to 2015) were searched for lower value services. The lower value services identified were categorized by type of care (diagnostics, treatment with and without medication), type of lower value service (not routinely provided or not provided at all), and ICD10 codes (international classification of diseases). The list was prioritized per ICD10 code, based on the number of lower value services per ICD10 code, prevalence, and burden of disease.


A total of 1366 lower value services were found in the 193 Dutch guidelines included in our study. Of the lower value services, 30% covered diagnostics, 29% related to surgical and medical treatment without drugs primarily, and 39% related to drug treatment. The majority (77%) of all lower value services was on care that should not be offered at all, whereas the other 23% recommended on care that should not be offered routinely. ICD10 chapters that included most lower value services were neoplasms and diseases of the nervous system. Dutch guidelines appear to contain more lower value services than UK guidelines. The prioritization processes revealed several conditions, including back pain, chronic obstructive pulmonary disease, and ischemic heart diseases, where lower value services most likely occur and de-adoption is warranted.


In this study, a comprehensive list of lower value services for Dutch hospital care was developed. A feasible method for prioritizing lower value services was established. Identifying and prioritizing lower value services is the first of several necessary steps in reducing them.


Choosing Wisely; De-adoption; De-implementation; Disinvestment; Guideline; Low-value; Medical reversal; Waste




Wammes JJ
van den Akker-van Marle ME
Verkerk EW
van Dulmen SA
Westert GP
van Asselt AD
Kool RB