Throughout the world, hospitals and health care professionals continue to confront the acute crisis of caring for patients with COVID-19. Focusing on care for patients who are critically ill has de-emphasized routine medical care, including wellness examinations, chronic disease management, elective surgical procedures, vaccinations, preventive health care, and screening for cancer and other diseases.1 It is estimated that nonemergent medical care decreased by up to 60% during the spring of 2020.1,2
Stringent hospital visitation policies and a fear of becoming infected while in the hospital or clinic have led many patients to defer or avoid necessary medical care, with severe consequences, including death from strokes, heart attacks, and other acute illnesses.3 However, there may be a silver lining to deferring certain types of routine care.4 For many years, studies have shown that the U.S. health care system provides a high volume of low-value care, defined as medical services for which the potential for harm or high cost generally outweighs the benefits.5–7 Low-value care is not only wasteful but often leads to a cascade of overtesting, overdiagnosis, overtreatment, and increased morbidity and mortality.8,9 Between 10% and 20% of the medical care prescribed in the United States is considered low value at an estimated cost of more than $300 billion annually.10,11
Tests and procedures often cited as providing low value include diagnostic imaging (e.g., magnetic resonance imaging, computed tomography), cancer screening in older patients, and many orthopedic and interventional pain management procedures.12–17 The value of the annual adult wellness examination has also been questioned because it does not measurably improve health outcomes and is often accompanied by low-value screening tests, such as electrocardiograms, thyroid function testing, and urinalyses, which often lead to unnecessary evaluations.9,18
Despite progress in identifying overused services through programs such as Choosing Wisely (https://www.choosingwisely.org), the Dartmouth Atlas Project (https://www.dartmouthatlas.org), and American Family Physician's Lown Right Care series (https://www.aafp.org/afp/rightcare), more needs to be done to reduce overuse in clinical practice.
How can the avoidance of routine care during the pandemic benefit patients? More than one in five adult wellness examinations includes an electrocardiogram; however, the U.S. Preventive Services Task Force recommends against performing this test in asymptomatic, low-risk adults because harms outweigh potential benefits.19,20 A decreased number of wellness examinations and nonemergency procedures during the pandemic has been associated with a 46% decrease in the number of patients receiving elective cardiac catheterizations.21 Data show that invasive approaches to managing patients with stable coronary artery disease are no better than appropriate medical management; therefore, it is likely that effects from the COVID-19 pandemic helped reduce costs and procedural risks with similar or better clinical outcomes for many patients.22
The COVID-19 pandemic has caused significant disruptions to our health care system and our lives. It has highlighted and exacerbated health disparities, social injustice, and systemic racism in medicine. We need to learn from the pandemic. Some call the pandemic a natural experiment in our health care system; however, the pandemic has also provided an opportunity to evaluate which medical services are truly necessary and what patients can do without.4 Family physicians need to provide patient-centered, evidence-based care that minimizes waste, overuse, and underuse. When most of the population have received an effective COVID-19 vaccine, the temptation to go back to normal will be difficult to resist. However, the COVID-19 pandemic should encourage clinicians to stop providing ineffective services that have not been demonstrated to improve patients' health.