Low-value care (LVC) refers to preventive, diagnostic, or therapeutic services that are overused, misused, or underused and where potential harms or financial costs outweigh expected clinical benefits. This includes the provision of ineffective, inappropriate, or non-cost-effective care, as well as the failure to deliver necessary services, with consequences for patients, healthcare professionals, and health systems. ^{1 , 2} Beyond its direct clinical and economic implications, LVC undermines key dimensions of the quadruple-value framework, including patient outcomes, patient experience, and cost efficiency. ³ Despite growing emphasis on value-based healthcare (VBHC), a persistent gap remains between the promotion of VBHC and the systematic reduction of LVC across healthcare systems, particularly within the Organisation for Economic Co-operation and Development (OECD). ⁴ To better connect these complementary aims, the ability to monitor LVC reliably and routinely across care settings in required. ⁵

Addressing these goals can support the routine monitoring, benchmarking, and de-implementation of LVC on regional, national, and international levels as well as through inter-country comparisons. ^{2 , 6} To date, health systems and international bodies have undertaken efforts to monitor and minimize the impact of LVC, ^{7 , 8} including efforts embedded within the OECD Health Care Quality Indicator (HCQI) Framework, which aims to assess system-level efficiency and effectiveness. ⁹ However, understanding the scope and effectiveness of these LVC measures within routine health quality monitoring remains limited, reflecting multiple opportunities to better refine measurement standardization, data availability, and the systematic use of LVC process-based performance assessment. ^{2 , 4 , 10}

In this context, established frameworks of healthcare quality measurement offer a useful foundation for addressing these limitations and have been applied successfully to support continuous quality improvement using clinical indicators. ¹¹ Among these, the Donabedian model assesses healthcare quality through structure, process, and outcome measures, where structure measures quantify available health system resources, process measures capture the actions taken during care delivery, and outcome measures assess the effects of care on patients’ health. ^{12 , 13} In the context of LVC monitoring, process measures have been identified as particularly relevant as they directly track care provided and can be observed consistently across multiple health service settings. ¹⁴ Moreover, from an applied behavioural perspective, process measures can further inform de-implementation strategies by enabling analyses of care provider behaviour and the care pathway mechanisms that shape service delivery on a systems level. ¹⁵

This utility of process measures is reflected in international initiatives such as Choosing Wisely, which has played a central role in the identification and monitoring of LVC across multiple OECD health systems. ¹⁶ The Choosing Wisely campaign, initiated in the United States in 2012, has since expanded to more than 30 countries, fostering global collaboration on defining LVC in concrete and measurable terms. Choosing Wisely recommendations encompass over 80 medical specialties and identify over 700 medical services deemed as low-value. A 2021 systematic review identified 131 sources that applied Choosing Wisely criteria across health settings to support interventions to reduce LVC, indicating wide adoption of Choosing Wisely criteria to frame LVC monitoring. ¹⁷ However, despite the wide adoption and evaluation of Choosing Wisely campaigns, the specific process measures used to operationalize routine LVC monitoring and to support de-implementation are often inconsistently defined and reported. ^{10 , 18} In addition, process measures of LVC are commonly validated using historical cohort data, thus, they are rarely designed for continuous monitoring, leaving a gap between measure validation and their routine use in quality improvement. ^{19 , 20}

This review was conducted in accordance with the Joanna Briggs Institute’s methodology for scoping reviews. ²¹ The review protocol was registered with the Open Science Framework (OSF; https://doi.org/10.17605/OSF.IO/YMDVF). ²² Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. ²³

This review identified a relatively small body of 14 sources that reported on the development of process-based measures for the routine monitoring of LVC across various healthcare settings, mostly emerging after 2020. This late emergence is noteworthy, as concerns regarding unnecessary and ineffective care have been documented for decades; with the term “low-value care” appearing explicitly in peer-reviewed literature around 2010, ⁵ followed shortly thereafter by the emergence of Choosing Wisely. ¹⁶ Further, a majority of sources originated in countries with more mature Choosing Wisely initiatives (i.e., The United States and Canada), indicating temporal growth in the development and uptake of structured approaches to identifying and monitoring LVC.

However, despite the growing interest in the monitoring and subsequent de-implementation of LVC, the limited volume and heterogeneity of evidence from this review suggests that routine LVC measurement remains underdeveloped for consistent application within systemwide monitoring efforts. Tables 2–5 collectively illustrate that existing routine measurement structures are predominantly focused on identification and quantification, with limited representation of de-implementation activities alongside the presentation of process measure construction. ²⁸

Together, these initial findings may suggest that while interest in routine LVC monitoring is increasing, its application may be fragmented and insufficiently linked to practice change. This pattern may highlight an important disconnect between the recognition of LVC as a health system priority and the availability of LVC measurements structures to support sustained practice change through routine monitoring efforts. Alternatively, this may reflect a continuing trend of measurement structures being described outside of de-implementation literature. ^{10 , 17}

Across the included sources, process measures were operationalized mostly within site specific and regional administrative claims or electronic health records, drawing on criteria derived from international initiatives such as Choosing Wisely and standardized ICD-10 and ICD-11 coding structures. While global Choosing Wisely initiatives have been instrumental in advancing consensus around what constitutes LVC, ^{7 , 14} findings from this review indicate substantial variation in how process measures are defined and interpreted in practice. Many sources relied on ratio-based approaches that were feasible within existing data infrastructures but that were also limited by proxy measures, coding dependence, and incomplete clinical detail. As a result, measures were often well suited to continually estimating LVC prevalence but were less capable of informing actionable care pathway level interventions.

This lack of cohesive direction is further reflected in the study selection process. Although approximately 900 sources advanced to full-text review, more than 600 in total were excluded because they did not explicitly report the structure of the process measures used, the methods for routine assessment, nor clear operational definitions of LVC, even when successful implementation of routine LVC monitoring was claimed. This limited disclosure of routine LVC measurement methods may constrain cumulative advancements in this field, further hampering efforts to translate conceptually aligned approaches into scalable monitoring systems. Without clearer articulation of measurement logic and operational assumptions successful implementation of monitoring systems may remain difficult to reproduce, benchmark, or adapt at scale. An opportunity to standardize and strengthen the reporting of routine LVC monitoring may therefore lie within established monitoring structures, such as those proposed by the OECD HCQI Framework, ⁹ which provides a system-level structure for applying shared measures more consistently across health settings.

However, considering the above, these heterogeneous applications of monitoring from a shared conceptual foundation may reflect purposeful adaptation to diverse data infrastructures and healthcare settings, thereby supporting the potential of future flexibility and applicability across different healthcare monitoring domains. Nonetheless, further work is needed to translate the conceptual alignment of what constitutes LVC into more cohesive and operationally consistent measurement structures that support shared directions in scalability. This current discordance may provide clear opportunities for routine process measurement to expand amongst national and international partners, through a shared conceptual underpinning while preserving contextual adaptability.

Considering these potential future applications, it is important to note that data and measurement limitations were pervasive across sources and frequently constrained the interpretability and usability of process measures. Common challenges included restricted data scope, definitional heterogeneity, and complex index construction, all of which pose barriers to comparability and routine implementation, even if supported by internationally adopted AIS, ICD-10, and ICD-11 coding structures. These limitations may partly explain why most identified measures were primarily used for algorithm or index construction rather than within real-time quality improvement or de-implementation initiatives through accessible methods, such as strategic data dashboards. Addressing these issues will likely require greater emphasis on measurement transparency, standardized nomenclature, and alignment with clinical workflows and behavioural mechanisms of care delivery across similar health systems.

Taken together, these findings suggest that while process-based measures hold considerable promise for routine monitoring and ultimately reducing LVC; stronger links between measurement development and de-implementation are needed. Future work should prioritize the design of process measures that are not only methodologically robust, but that are also explicitly intended for use in de-implementation strategies, with attention to organizational context, data feasibility, and end-user needs. Building on this foundation, there are clear opportunities to expand routine LVC process measurement at both national and cross-national levels, across similar and dissimilar healthcare systems, and to explore areas for result dissemination amongst care providers (i.e., via strategic dashboards).

Progress in these areas requires clearer articulation of measurement logic aligned with reporting standards that support transparent interpretation, adaptation, and replicability. Enabling clear interpretation of routine measurement structures could be leveraged to assess the real-world impact of Choosing Wisely recommendations, strengthening alignment between LVC measurement and Choosing Wisely definitions of LVC. Such feedback loops may also inform the development of new LVC recommendations and support subsequent de-implementation strategies through closer clinical and patient partnerships. Without these advances, the potential for routine measurement to drive sustained reductions in low-value practices may remain unrealized.

This scoping review is subject to several methodological limitations. In line with JBI and PRISMA-ScR guidance, no formal assessment of study quality or risk of bias was undertaken, which may limit interpretation of whether observed patterns reflect well-validated measurement approaches or artefacts of underlying data and design limitations. The review is also limited by reliance on the reporting quality of included sources, which was frequently heterogeneous due to a high variety of LVC foci. Further, because this review focused on mapping existing measures rather than evaluating their performance, conclusions should be interpreted as descriptive of methodological approaches currently in use rather than indicative of best or preferred measurement practice. Finally, the use of routine process measures to support de-implementation may be underrepresented in this review, as such initiatives are not always reported alongside detailed measurement structures. As a result, the alignment between routine measurement and de-implementation efforts may be greater in practice.

Existing evidence demonstrates strong conceptual alignment in definitions of LVC, largely informed by initiatives such as Choosing Wisely, alongside growing recent interest in the development of routine process-based measures. This shared conceptual foundation, combined with the adaptability of measures across diverse data infrastructures, highlights important opportunities for applying LVC monitoring across healthcare settings.

However, substantial variation currently exists in how these concepts are operationalized into scalable, comparable, and practical routine measurement structures. Despite growing recognition of LVC as a major health system challenge, the reporting of routine process-based measurements alongside system level monitoring and de-implementation remains limited. This may reflect both a gap in how measures are designed for practice change and a separation in how measurement and de-implementation activities are reported in the literature.

Advancing routine LVC monitoring will require clearer articulation of measurement logic, improved transparency in reporting, and the development of end-user-oriented tools that translate data into actionable insights to actively support de-implementation. Aligning these efforts with established system-level frameworks may further enable national and cross-national monitoring, allowing routine process measurement to more effectively contribute to meaningful and sustained reductions in low-value practices.

Ethical approval and consent were not required.