Intensive Care Med

https://doi.org/10.1007/s00134-024-07670-7

REVIEW

Interventions to reduce low‑value care

in intensive care settings: a scoping review
of impacts on health, resource use, costs,
and the environment
Jake T. W. Williams1* , Florencia Moraga Masson1,2, Forbes McGain1,3,4,5, Rachel Stancliffe6, Julia K. Pilowsky7,8,
Nhi Nguyen7,9 and Katy J. L. Bell1

© 2024 The Author(s)

Abstract
Purpose: Low-value care is common in intensive care units (ICUs), unnecessarily exposing patients to risks and
harms, incuring costs to the patient and healthcare system, and contributing to healthcare’s carbon footprint. We
aimed to identify, collate, and summarise published evidence on the impact of interventions to reduce low-value care
in ICUs.
Methods: We searched MEDLINE, Embase, and Cochrane CENTRAL from inception to 22 September 2023 for evalu-
ations of interventions aiming to reduce low-value care, supplemented by reference lists and recently published
articles. We recorded impacts on the low-value target, health outcomes, resource use, cost, and the environment.
Results: From 1155 studies screened, 32 eligible studies were identified evaluating interventions to reduce: routine
blood testing (n = 13), routine chest X-rays (n = 10), and other types (or multiple types) of low-value care (n = 9). All
but 3 of the interventions found reductions in the immediate low-value care target (usually the primary outcome).
Although the small sample size of most included studies, limited their ability to detect impacts on other outcomes,
many interventions were also associated with improved health outcomes and financial savings. The only study that
reported environmental impacts found the intervention was associated with reduced carbon dioxide equivalent
­(CO2-e) emissions.
Conclusions: Interventions to reduce low-value care in ICUs may have important health, financial, and environmen-
tal co-benefits. Further research may inform wider scale-up and sustainability of successful strategies to decrease
low-value healthcare. More empirical evidence on potential environmental benefits may inform policies to lower
healthcare’s carbon footprint.
Keywords: Intensive care, Low-value care, Health outcomes, Cost, Environmental impact, Review

*Correspondence: [email protected]
1
Faculty of Medicine and Health, School of Public Health, University
of Sydney, Sydney, NSW, Australia
Full author information is available at the end of the article
Introduction
Low-value care, also called overuse or unnecessary care, Take‑home message
refers to healthcare interventions with very little to
We aimed to identify, collate, and summarise published evidence on
no benefit to patients. In the intensive care unit (ICU), the impacts of interventions to reduce low-value care in intensive
thresholds to intervene tend to be lower and patients care units (ICUs). Multiple evidence-based interventions may reduce
are more vulnerable to the adverse effects of interven- low-value care in ICUs with important health, financial, and environ-
mental co-benefits. Further research may inform wider scale-up and
tions. As a result, low-value care is common [1–3], with sustainability of successful strategies to decrease low-value health-
critically unwell patients undergoing frequent diagnostic care. More empirical evidence on potential environmental benefits
imaging, pathology testing, treatments, and other proce- may inform policies to lower healthcare’s carbon footprint.
dures that have little or no benefit to them [2].
These interventions fail to improve patient health
were included in this review if they met the following
outcomes, with a recent meta-analysis reviewing inter-
participant, concept, and context (PCC) criteria:
ventions to reduce diagnostic tests in the ICU finding
that tests could be reduced without significant changes
•  Participants: all critically unwell patients, including
to hospital mortality [4]. Low-value care also exposes
all health conditions and ages.
patients to risks and harms, uses up limited nurse and
•  Concept: the effectiveness of interventions self-iden-
clinician time, has opportunity costs for patients and cli-
tifying to reduce the use of low-value care, includ-
nicians, and incurs financial costs for the patient, health
ing outcomes related to health, resource use, costs,
facility, and health system [5]. For all these reasons, there
and environmental impact. Resource use is broadly
is already good reason to reduce low-value care in the
defined and considered to include efficiency and
ICU.
more effective use of clinical staff ’s time (which may
However, there is also increasing awareness of the envi-
include continuing education to achieve this).
ronmental impacts of healthcare and the need to deliver
•  Context: general intensive care settings, including
sustainable care [1, 6]. The Centre for Sustainable Health-
medical and surgical intensive care units (but not
care’s Principles of Sustainable Clinical Practice advocate
cardiac or cardiothoracic units).
for lean service delivery by reducing low-value activi-
ties and their impacts [7], and this is a compelling way
to make ICUs more sustainable [8]. To the best of our We identified peer-reviewed publications of inter-
knowledge, no review has sought to include the environ- vention studies, including randomised trials, non-ran-
mental benefits of reducing low-value care in the ICU. domised trials, and quality improvement studies, to
To inform further intervention and implementation identify the effectiveness of interventions to reduce low-
research to reduce low-value care in ICUs, we under- value care. Conference abstracts were excluded. Studies
took a scoping review of published evidence on the topic. published at any time and in any language were eligible
Specifically, we aimed to identify, collate, and summa- and translated using Google Translate (https://​www.​
rise evidence on the impacts of interventions to reduce google.​com/​trans​late) as required.
low-value care in hospital ICUs on health, resource use,
financial costs, and the environment. Information sources
We used the following automated tools from the System-
Methods atic Review-Accelerator [12] to develop our search: Word
Protocol and registration Frequency Analyser (uses pre-identified target papers to
This scoping review was conducted in accordance with identify common text words and MESH terms), Search
the Joanna Briggs Institute Manual for Evidence Synthe- Refinery (supports refinement of the search strategy
sis [9] and the protocol was registered with Open Sci- so that it is more efficient in finding relevant literature
ence Framework registry [10]. We report our findings and leaving out irrelevant literature) [13], and Polyglot
according to the Preferred Reporting Items for System- Translator (translates searches for MEDLINE to other
atic Reviews and Meta Analyses Extension for Scoping databases) [14]. We searched MEDLINE, Embase, and
Reviews (PRISMA-ScR) (electronic supplementary mate- Cochrane CENTRAL to identify potentially relevant
rial, ESM, 1) [11]. studies on 22 September 2023. The full search strategy
for each database is included in electronic supplementary
material, ESM, 2. This was supplemented by reference
Eligibility criteria lists from two recently published journal articles by Baid
Studies reporting on the effectiveness of interventions to et al. (references cited in “Avoid and reduce: tackling low-
reduce low-value care in hospital intensive care settings value care” section) [1] and Hooper et al. (all references)
[4]. We also included two recently published journal arti- records that were included in the review. Two of these
cles by Pilowsky et al. and Siegal et al. [15, 16]. reported on the same study [18, 19].

Selection of sources of evidence Characteristics of sources of evidence

We collated all potentially relevant records in EndNote Included records are summarised in Table 1. Records
X9 (Clarivate Analytics, PA, USA) and uploaded them to were published between 1993 and 2024 in the United
Covidence (Veritas Health Innovation, Australia; https://​ States (n = 12), France (n = 5), Australia (n = 4), Canada
www.​covid​ence.​org) where duplicate studies were auto- (n = 4), the Netherlands (n = 2), New Zealand (n = 2),
matically removed, with additional duplicates manually Japan (n = 1), Italy (n = 1), and Switzerland (n = 1).
removed by a reviewer. One reviewer screened titles and Studies used quality improvement (n = 26), cohort
abstracts (FMM) and two reviewers screened full texts (n = 2), or randomisation-based (n = 4) methods in
(FMM and JTWW). Disagreements were resolved by a adult (n = 32) or paediatric (n = 2) intensive care set-
third reviewer (KJLB). tings. The quality of included records was rated as Level
4 (n = 26), Level 3 (n = 3), or Level 2 (n = 3).
Data charting Records described interventions to reduce routine
Two authors developed a data extraction tool and blood tests (n = 13; 41%) [16, 18–29], routine chest
extracted relevant data after pilot testing and refining X-rays (n = 10; 31%) [30–39], and multiple or other
the tool (JTWW and KJLB). The extraction tool included types of low-value care (n = 9; 28%) [15, 40–47]. Inter-
authorship and publication information, objectives of the ventions had multiple components, which commonly
study, study design, intervention and comparator, and included education programmes for staff, implementa-
impact on health outcomes, resource use, cost, and the tion of testing guidelines, modifications to test order-
environment. The full data charting tool is included in ing processes, and staff feedback pathways. Of the 32
ESM 3. The quality of individual studies was rated using records, 29 reported effects on the low-value care out-
the Oxford Centre for Evidence-Based Medicine Levels come targeted by the intervention, 24 reported effects
of Evidence rating system, from 1 to 5 [17]. on health outcomes, 17 reported financial savings, and
1 reported effects on environmental outcomes. Details
Synthesis of results are provided in ESM 4.
We grouped studies by the type of low-value care they
examined and undertook qualitative synthesis of the Reducing routine blood tests
results. The outcomes of each study were classified Thirteen studies described interventions to reduce
into the following categories: low-value care outcomes, blood tests [16, 18–29] and 11 of these were associ-
health outcomes, resource use outcomes, financial out- ated with an improvement in a low-value care outcome
comes, and environmental outcomes. The low-value [16, 18, 20–26, 28, 29]. Interventions were associated
care outcomes were the specific target that the interven- with reductions in the number of overall and unnec-
tion aimed to reduce, such as unnecessary blood tests or essary tests per patient-day (n = 19) [16, 18, 21–26,
X-rays. Health outcomes included direct patient relevant 29], the number of blood collection tubes used (n = 1)
outcomes such as morbidity and mortality, as well as sur- [20], and an increase in the proportion of appropriate
rogates for these such as ICU length of stay and number tests (n = 1) [28]. Nine studies reported on surrogate
of blood transfusions. Financial outcomes included all or direct health outcomes [16, 20–23, 25, 26, 28, 29].
costs, and environmental outcomes included any envi- Interventions were associated with a decrease in the
ronmental impacts that were reported. volume of blood taken for testing (n = 2) [20, 26], the
number of red cell transfusions (n = 1) [20], the pro-
Results portion of patients requiring mechanical ventilation
Selection of sources of evidence (n = 1) [16], and length of stay in the ICU (n = 1) [16].
Figure 1 summarises the selection of source of evi- There were no adverse health effects found in the other
dence processes. We identified 1155 unique records six studies reporting on health outcomes. Eight stud-
from online database searches and other sources. ies reported financial outcomes, which suggested sav-
Based on the title and abstract, we excluded 1046 ings per year, per patient, and per patient-day [16, 18,
of these records and sought 99 for full-text review. 21, 23, 25–27, 29]. Only one study reported an envi-
Three of these records were not retrieved because no ronmental outcome. This study reported a decrease in
full text was identified. Of the remaining 96 records, carbon dioxide equivalent ­(CO2-e) emissions associated
64 were excluded (for reasons see Fig. 1), leaving 32 with pathology testing over the study period, largely
 Identification of studies via databases and other sources

Identification

Records identified from:

Records removed before
Embase (n = 835)
screening:
MEDLINE (n = 277)
Duplicate records removed
CENTRAL (n = 62)
(n = 65)
Other sources (n = 36)

Records screened Records excluded**

(n = 1145) (n = 1046)

Reports sought for retrieval Reports not retrieved

(n = 99) (n = 3)
Screening

Reports assessed for eligibility Reports excluded:

(n = 96) Conference abstract (n = 28)
Not intervention study (n = 27)
Not low value care (n = 4)
No relevant outcome (n = 1)
Not ICU setting (n = 1)
Insufficient details (n = 1)
Ongoing study (n = 1)
Duplicate (n = 1)
Included

Studies included in review

(n = 32)

Fig. 1 PRISMA flow diagram

attributed to reduction in use of arterial blood gas tests 56%) [37]. The remaining seven studies reported inter-
[16]. Details are provided in Table 2 and ESM 4. ventions associated with fewer X-rays per patient or
patient-day (n = 6) [30, 32, 34–36, 39] or an increase
Reducing routine chest X‑rays in the proportion of X-rays that resulted in a change
Ten studies described interventions to reduce rou- in patient management (n = 1) [33]. All ten studies
tine chest X-rays, all of which were associated with an reported surrogate or direct health outcomes [30–39]
improvement in a low-value care outcome [30–39]. and most (n = 9) reported no changes [30–34, 36–39].
Three high-quality randomised studies reported fewer In one study, the intervention was associated with a
X-rays per patient-day (1.09 vs 0.75) [38], and per decrease in the proportion of patients requiring pul-
patient (6.8 vs 4.4) [31], and an improvement in the monary artery catheters [35]. Five studies reported
proportion of tests with new findings (7.2% vs 66%) financial outcomes, all of which suggested cost savings
[37] that prompted a change in management (5.5% vs [30, 33–36]. No environmental impacts were reported.
Details are provided in Table 3 and ESM 4.
Table 1 Characteristics of 32 included studies
Author, year Quality Country ICU setting Study design Type of low-value care Sample size

Pilowsky (2024) [16] Level 4 Australia Adult QIS Routine pathology tests 22,210 patients
Siegel (2023) [15] Level 2 Canada Adult Stepped-wedge cluster-ran- Blood tests (volume) 27,411 patients
domised trial
Bodley (2023) [20] Level 4 Canada Adult QIS Blood collection volume, 2096 patients
including for pathology test-
ing and waste
Malin (2023) [36] Level 4 USA Child QIS CXR 668 patients
Conroy (2021) [22] Level 4 USA Adult QIS Routine pathology tests 24 bed ICU
Ogasawara (2020) [45] Level 4 Japan Adult and Child QIS Stress ulcer prophylaxis 100 patients
Clouzeau (2019) [21] Level 3 France Adult Prospective cohort study Laboratory tests 5707 patients
Dhanani (2018) [23] Level 4 Australia Adult QIS Laboratory blood tests 3250 patients
Yorkgitis (2017) [46] Level 4 USA Adult QIS Blood tests, CXR 307 patients
Brogi (2017) [30] Level 3 Italy Adult Retrospective cohort study CXR 4134 patients
Kotecha (2017) [24] Level 4 USA Adult QIS Unnecessary laboratory tests 207 patient-daysa
Keveson (2017) [34] Level 4 USA Adult QIS CXR 2 × 21 bed ICUs
Raad (2017) [41] Level 4 USA Adult QIS Blood tests 18 bed ICU
Rachakonda (2017 [27] Level 4 Australia Adult QIS Laboratory tests 2778 patients
Resnick (2017) [39] Level 4 USA Adult QIS CXR 197 patients
Musca (2016) [26] Level 4 Australia Adult QIS Coagulation blood tests 253 patients
Murphy (2016) [40] Level 4 USA Adult QIS Blood tests, CXR 22,563 patients
Merkeley (2016) [25] Level 4 Canada Adult QIS Blood tests 1140 patients
Gutsche (2013) [43] Level 4 USA Adult QIS Blood transfusions 495 patients
Hejblum (2009) [38] Level 2 France Adult Cluster randomised crossover CXR 849 patients
study
Prat (2009) [44] Level 4 France Adult QIS CXR, blood tests 1175 patients
Kumwilaisak (2008) [28] Level 4 USA Adult QIS Blood tests 1117 patients
Graat (2007) [32] Level 4 Netherlands Adult QIS CXR 1376 patients
Hendriske (2007) [33] Level 4 Netherlands Adult QIS CXR 736 patients
Clec’h (2007) [37] Level 2 France Adult Randomised controlled trial CXR 165 patients
Krinsley (2003) [35] Level 4 USA Adult QIS CXR 2564 patients
Krivopal (2003) [31] Level 3 USA Adult Pseudo-randomised study CXR 94 patients
Seguin (2002) [47] Level 4 France Adult QIS Blood tests, CXR 289 patients
Mehari (2001) [19]b Level 4 NZ Adult QIS Blood tests 94 patients
Merlani (2001) [29] Level 4 Switzerland Adult QIS Blood tests 549 patients
Mehari (1997) [18]b Level 4 NZ Adult QIS Blood tests 199 patients
Roberts (1993) [42] Level 4 Canada Adult QIS blood tests, CXR, ECG 1883 patients
CXR chest X-Ray, ECG electrocardiogram, ICU intensive care unit, NZ New Zealand, QIS quality improvement study, USA United States of America
a
Number of participants not reported
b
Report on the same study

Reducing other types of low‑value care or multiple types trial found that smaller volume blood test tubes resulted
of low‑value care in 10 fewer blood units transfused per 100 patients dur-
Six studies aimed to reduce both laboratory testing and ing their ICU stay [15]. In the seven studies that meas-
diagnostic imaging, [40–42, 44, 46, 47] of which five were ured health outcomes, these were no worse under
associated with an improvement in a low-value care out- intervention than control [15, 40–43, 45, 46]. Four stud-
come [40–42, 44, 47]. Two studies aimed to reduce blood ies reported financial outcomes, all of which suggested
transfusions [15, 43], and one aimed to reduce use of cost savings [40, 42, 44, 47]. No environmental impacts
stress ulcer prophylaxis [45], all of which were associated were reported. Details are provided in Table 4 and ESM
with an improvement in a low-value care outcome. A 4.
large high-quality stepped wedge randomised controlled
Table 2 Impacts of 13 studies reporting interventions to reduce routine blood testing
Author Quality Intervention Low-value care outcomes Health outcomes Financial outcomes Environmental outcomes

Pilowsky (2024) [16] Level 4 Education, audit, feedback 1.7 fewer pathology tests per 12% fewer patients receiving AUD 918,497.50 saved per year 1.83 less tonnes ­CO2-e
patient-day (8.68 vs 6.98) mechanical ventilation (37.8 (group results not reported) emitted per year (12.88
vs 33.1; p < 0.001) vs 11.05)
1.5 less hours in ICU (50.6 vs
49.1; p = 0.032)
Bodley (2023) [20] Level 4 Education, bedside checklist, 1.4 fewer blood collection 2.2 fewer red cell transfusions NA NA
electronic order modifica- tubes per patient-day (6.3 vs per 100 patient-days (10.5 vs
tions, audit, feedback 4.9; p = 0.005) 8.3; p = 0.01)
7 mL less blood collected for
testing per patient-day (41.1
vs 34.1; p = 0.009)
Conroy (2021) [22] Level 4 Education, adjusting test 1.2 fewer laboratory tests per No change NA NA
ordering set patient-day (9.5 vs 8.3)
Clouzeau (2019) [21] Level 3 Education, new ordering 22.1 fewer tests per ICU- No change Euro 135 saved per patient- NA
policy patient-day (37.3 vs 15.2; day (239 vs 104; p < 0.0001)
p < 0.001)
Dhanani (2018) [23] Level 4 Prescribing guidelines, new 1.3 fewer pathology tests per No change AUD 28.26 saved per patient NA
laboratory form, education patient-day (4.7 vs 3.4) per day (group results not
reported)
Kotecha (2017) [24] Level 4 Guidelines, education 2.1 fewer tests per patient-day NA NA NA
(3.5 vs 1.4)
Rachakonda (2017) [27] Level 4 Authorisation of blood tests by NA NA No change NA
ICU specialist
Merkeley (2016) [25] Level 4 Education, ICU checklist, a rub- 0.14 fewer routine complete No change CAD 11,200.24 saved per year
ber stamp indicating tests blood count tests per (group results not reported)
not indicated, prompt in patient-day (0.97 vs 0.83)
electronic ordering system 0.13 fewer routine electrolyte/
renal panel tests per patient-
day (0.96 vs 0.83)
Musca (2016) [26] Level 4 Guideline, education 0.529 fewer coagulation 1.79 mL less blood collected USD 17.23 saved per bed-day NA
profile tests per patient-day for coagulation testing per (28.47 vs 11.24)
(1.068 vs 0.539; p < 0.001) patient-day (group results
0.437 fewer coagulation pro- not reported)
file, activated partial throm-
boplastin time, international
normalised ratio tests per
patient-day (1.088 vs 0.651;
p < 0.001)
0.685 fewer full blood count,
urea, electrolytes and
creatine, and liver function
tests per patient-day (5.367
vs 4.682; p = 0.003)
 Discussion
Environmental outcomes

We reviewed 32 studies reporting interventions to reduce

low-value care in the ICU, most of which investigated
strategies to reduce routine pathology tests and chest
X-rays. Studies described interventions that included
education programmes, testing guidelines, modifica-
tions to test ordering processes, incentives, and audit and
NA

NA

NA
feedback. Most studies reported associations with mod-
erate reductions in low-value care (the immediate target
for cardiac ICU (group results
NZD 64.61 saved per patient

NZD 71.33 saved per patient

CHF 68.4 saved per patient-

of the intervention). In all the studies, the interventions

results not reported) [18]
for general ICU (group

day (group results not

appeared safe, with none reporting adverse health out-

Financial outcomes

not reported) [18]

comes and some reporting health co-benefits. All stud-

ies that measured financial costs reported savings. Only
one study reported environmental impacts. Although
reported)

most of the studies used a before-and-after study design,

there were three randomised controlled trials that pro-
NA

vided more robust estimates of effect. Only two studies

included children. None of the studies was conducted in
a low- or middle-income country.
Our findings are generally consistent with other stud-
Health outcomes

ies. A recent systematic review of the safety and efficacy

of interventions to reduce routine diagnostic tests in
No change

No change

the ICU found decreases in testing and associated costs

without increases in hospital mortality or adverse events,
consistent with the findings of this review [4]. We have
NA

included an additional nine studies that were not part of

Intervention effects sustained
4.3 fewer tests per patient-day

post-implementation (1997
general ICU (61.04 vs 53.34)

tests per patient-day (8.2 vs

that review (seven were published since the end of the

7.7 fewer tests per patient in

Guideline, education, feedback 3.4 fewer blood gas analysis

Low-value care outcomes

AUD Australian Dollar, CAD Canadian Dollar, CHF Swiss Franc, NZD New Zealand Dollar, USD United States Dollar

study’s literature search period) [15, 16, 20–22, 24, 36, 43,
(20.7 vs 16.4; p < 0.001)

45]. A narrative review of interventions to reduce routine

blood testing in the ICU identified six types of interven-
4.8; p < 0.001)
to 2001) [19]

tion that were used: education and guidance, audit and

feedback, gatekeeping, computerised physician order
entry, multifaceted, and interventions using artificial
[18]

intelligence (machine learning) [48]. The authors found

that all intervention types could effectively reduce test-
ing [48]. Our study described combinations of multiple
types of intervention, which makes it difficult to evaluate
whether some types were more effective than others. A
meta-analysis found interventions to reduce pathology
Quality Intervention

and chest radiograph testing were not associated with

Guideline

Guideline

increased hospital mortality [4]. A systematic review also

found that reductions in routine blood testing of criti-
cally ill patients can be associated with reduced blood
transfusion rates and costs without any adverse patient
Level 4

Mehari (1997) [18] (2001) [19] Level 4

Level 4

outcomes [49].
Health benefits and economic savings provide compel-
ling arguments to increase efforts to limit low-value care
Table 2 (continued)

Kumwilaisak (2008) [28]

in the ICU. Although we did not investigate opportunity

costs in terms of clinician time, this is also likely to be
Merlani (2001) [29]

significant [50]. Freeing up ICU nurses from spending

time on routine tests means they are more able to attend
to the acute needs of patients.
Author
Table 3 Impacts of 10 studies reporting interventions to reduce routine chest X-rays
Author Quality Intervention Primary outcomes Health outcomes Financial outcomes

Malin (2003) [36] Level 4 Criteria for CXR 48% absolute difference in proportion of No change USD 300,000 saved to patients over study
intubated patients receiving daily CXR period (group results not reported)
(79% vs 31%) USD 60,000 saved to hospital over study
period (group results not reported)
Brogi (2017) [30] Level 3 Routine use of lung ultrasound 0.55 fewer CXRs per patient (0.97 vs 0.42) No change Euro 22,104 saved over study period
(47,090 vs 24,986; p = 0.012)
Keveson (2017) [34] Level 4 Clinically indicated CXR, education 589 fewer CXRs per 1000 non-admission No change USD 191,600 saved per year in medical ICU
and non-procedural days in medical (group results not reported)
ICU (919 vs 330; p < 0.001) USD 224,200 saved per year in surgical ICU
346 fewer CXRs per 1000 non-admission (group results not reported)
and non-procedural days in surgical ICU
Resnick (2017) [39] Level 4 Guideline, clinically indicated CXR 16.2% fewer CXRs per patient-day (57.1 vs No change NA
40.9; p < 0.01)
Hejblum (2009) [38] Level 2 Clinically indicated CXR 0.34 fewer CXRs per patient-day of No change NA
mechanical ventilation (1.09 vs 0.75;
p < 0.0001)
Clec’h (2008) [37] Level 2 Clinically indicated CXR 58% absolute difference in proportion of No change NA
CXRs with new findings (7.2% vs 66%;
p < 0.0001)
50.9% absolute difference in proportion
of CXRs prompting change in manage-
ment (5.5% vs 56.4%; p < 0.0001)
Graat (2007) [32] Level 4 Clinically indicated CXR 0.5 fewer CXRs per patient-day (1.1 vs 0.6; No change NA
p < 0.05)
Hendrikse (2007) [33] Level 4 Clinically indicated CXR 16% absolute difference in proportion of No change Euro 82,500 saved per year (group results
CXRs prompting change in manage- not reported)
ment (1.9% vs 17.9%; p < 0.001)
Krinsley (2003) [35] Level 4 Form indicating the reason every 0.135 fewer CXRs per patient-day (0.606 4.5% absolute difference in proportion USD 109,968 saved over study period
CXR was ordered vs 0.471; p < 0.0001) of patients requiring pulmonary artery (group results not reported)
catheters (8.5% vs 4%; p < 0.0001)
Krivopal (2003) [31] Level 3 Clinically indicated CXR 2.2 fewer CXRs per patient (6.8 vs 4.4; No change NA
p = 0.007)
CXR chest X-ray, USD United Stated Dollar
Table 4 Impacts of nine studies of interventions to other types of low-value care or multiple types of low-value care
Author Quality Intervention Low-value care outcomes Health outcomes Financial outcomes

Siegal (2023) [15] Level 2 Small-volume tubes Standard-volume tubes in ICU storage 9.84 less red blood cell units transfused NA
areas post-intervention were 0.02%- per 100 patients during ICU stay (0.8
2.9% of total tubes counted vs 0.71; p = 0.04)
Ogasawara (2020) [45] Level 4 Checklist, change to ordering system 62% absolute difference in the propor- No change NA
tion of patients receiving stress ulcer
prophylaxis (100% vs 38%; p < 0.001)
Raad (2017) [41] Level 4 Education, electronic medical record 12.48 fewer laboratory tests per No change NA
changes patient-day (39.43 vs 26.95; p < 0.001)
6.21 fewer iSTAT laboratory tests per
patient-day (7.37 vs 1.16; p < 0.001)
Yorkgitis (2017) [46] Level 4 Daily checklist change No change No change NA
Murphy (2016) [40] Level 4 Education, financial incentives, feed- 1.6 fewer arterial blood gas tests per 1.7% lower absolute risk of ICU mortal- USD 772,048 saved per year
back encounter (3.9 vs 2.3; p < 0.005) ity (6.3% vs 4.6%; p < 0.005)
1.1 fewer CXR per encounter (3.5 vs 2.4; 1.8% lower absolute risk of hospital
p < 0.005) mortality (7% vs 5.2%; p < 0.005)
0.1 fewer utilised red blood cell units
per encounter (0.6 vs 0.5; p < 0.005)
Gutsche (2013) [43] Level 4 Clinical practice guideline, education, 6.6% absolute difference in unneces- No change NA
feedback sary transfusions (14.7% vs 8.1%;
p = 0.0016)
Prat (2009) [44] Level 4 Guideline, education, feedback 0.3 fewer CXRs per patient-day (0.75 vs NA Euro 58 saved per patient ICU day (114
0.45; p < 0.001) vs 56)
0.11–0.56 fewer routine laboratory tests
per patient (varied depending on the
type of test, see ESM 4)
Seguin (2002) [47] Level 4 Inform physicians of test costs 0.63 fewer urinary electrolyte tests per NA Euro 75 saved per admission (341 vs 266;
admission (1.16 vs 0.53; p < 0.01) p < 0.05)
0.8 fewer arterial blood gas tests per
admission (1.84 vs 1.04; p = 0.01)
Roberts (1993) [42] Level 4 Policy change 18% fewer tests per ICU day (42.6 vs No change CAD 121.84 saved per admission
34.9)
CAD Canadian Dollars, ICU intensive care unit, iSTAT​ laboratory tests available though point of care
 Only one of the included studies investigated envi- decrease in low-value care. To achieve this, studies may
ronmental benefits from limiting low-value care. There also investigate if a particular type of intervention is more
is increasing recognition that not only does climate effective than others and whether this varies by type of
change impact health, but that health care itself is pol- low value care, and by setting. Such evidence would ena-
luting and contributes substantially to the greenhouse ble policy makers and clinicians to choose the most effec-
gas emissions driving the climate crisis [51]. Most of tive and efficient strategy that best addresses their needs.
these emissions come directly from healthcare prod-
Supplementary Information
ucts and the delivery of healthcare services. This means The online version contains supplementary material available at https://​doi.​
that to achieve net zero health systems, we must lower org/​10.​1007/​s00134-​024-​07670-7.
the footprint of clinical care itself [2, 3]. The ICU is a
carbon hotspot within hospitals, which themselves Author details
account for a large proportion of healthcare’s total foot- 1
Faculty of Medicine and Health, School of Public Health, University of Sydney,
print [1]. Interventions that are effective in reducing Sydney, NSW, Australia. 2 Western Health, Sunshine Hospital, Melbourne, VIC,
Australia. 3 Department of Critical Care, University of Melbourne, Melbourne,
low-value care in the ICU will, therefore, help reduce VIC, Australia. 4 Department of Anaesthesia, Western Health, Footscray, VIC,
healthcare’s ­CO2-e emissions. Increased implementa- Australia. 5 Department of Intensive Care, Western Health, Footscray, VIC,
tion of “less is more” interventions are likely to have Australia. 6 Centre for Sustainable Healthcare, Oxford OX2 7DL, UK. 7 Agency
for Clinical Innovation, St Leonards, NSW, Australia. 8 Faculty of Medicine
significant co-benefits across health, costs, and envi- and Health, Kolling Institute, University of Sydney, Sydney, NSW, Australia.
ronmental outcomes [52]. 9
Sydney School of Medicine (Nepean Clinical School), University of Sydney,
Strengths of this scoping review are the multidiscipli- Kingswood, NSW, Australia.

nary author team, which includes ICU clinicians, com- Funding

prehensive search of large databases supplemented by Open Access funding enabled and organized by CAUL and its Member
reference searches, and a review process involving two Institutions. Open Access funding enabled and organized by CAUL and its
Member Institutions. This work was funded by Faculty of Medicine and Health,
authors for most steps. Our study also has limitations. University of Sydney with Grant number SC4167 (Jake TW Williams) and by
Many of the studies were designed to detect a difference National Health and Medical Research Council with Grant number 2019/
in the low-value outcome but not differences in other GNT1174523 (Katy JL Bell).
outcomes such as mortality. This issue of low-quality Data availability
evidence based on before-and-after comparisons was No new data were created or analysed in this study. Data sharing is not
also noted previously [4]. While the evidence appears applicable to this article. Data extracted from included studies in available in
the Online Appendix.
to show no adverse health impacts from interventions
targeting low value care, larger studies using robust Declarations
designs (ideally randomised controlled trials) are needed
Conflict of interest
to confirm this. There was only one reviewer for the title The authors declare no other conflicts of interest.
and abstract screening stage, which may have meant
some relevant studies were missed. In addition, the
Open Access
search for relevant articles relied on studies to include the This article is licensed under a Creative Commons Attribution-NonCommercial
term low-value care or similar. This means that studies 4.0 International License, which permits any non-commercial use, sharing,
that may be about reducing low-value care, but not using adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a
this term, would have been missed. Our search only iden- link to the Creative Commons licence, and indicate if changes were made. The
tified studies from high-income counties despite medi- images or other third party material in this article are included in the article’s
cal overuse being a problem in low- and middle-income Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence
countries and other low-resource settings [53–55]. Given and your intended use is not permitted by statutory regulation or exceeds the
the high carbon intensity of these settings, the environ- permitted use, you will need to obtain permission directly from the copyright
mental impact of low-value care may be significant [56]. holder. To view a copy of this licence, visit http://creativecommons.org/
licenses/by-nc/4.0/.
Future research may investigate ways to reduce low-
value care in paediatric ICUs, and in ICUs in low- and
Publisher’s Note
middle-income countries [53]. More empirical evidence Springer Nature remains neutral with regard to jurisdictional claims in pub-
is also needed on the impact of reductions in low-value lished maps and institutional affiliations.
care in ICUs on environmental outcomes such as C ­ O2-e
[8]. Where feasible, large intervention studies may
include life cycle assessments, as has been proposed for Received: 19 June 2024 Accepted: 21 September 2024
randomised clinical trials [57]. Further research is needed
to define the best implementation strategies to inform
wider scale-up and sustainability of interventions to
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