Addressing the challenge of low-value preoperative care: the need to change systems, mindsets and practices towards quality care

John et al.’s (2026) study adds compelling real-world evidence to the growing literature on the significant negative impact of low-value preoperative care [1, 2]. They reveal a system not simply providing unnecessary testing, but the persistence of delivery models insufficiently anchored in patient outcomes and value. By analyzing data from a private payer in Brazil from 2018 to 2023, the authors found that 57.5% of 27 678 elective low-risk urology, gynecology, and digestive surgical procedures were preceded by at least one preoperative test. Importantly, each additional preoperative consultation was associated with a 72% increase in the odds of undergoing at least one preoperative test, highlighting how organizational patterns and clinical routines perpetuate cascades of low-value activities. Overall, preoperative consultation and tests represented more than USD $4 million in expenditure with no proven benefit for patients. Emergency visits and rehospitalization rates after surgery were similar between patients undergoing preoperative tests and those undergoing no preoperative tests. John et al. (2026) modelled the impact of cost savings by decreasing low-value preoperative services: a 50% reduction could finance 1325 inguinal herniorrhaphies, 906 laparoscopic cholecystectomies, 2370 vasectomies, or 1108 laparoscopic salpingectomies. John et al.’s (2026) study shows that overuse in perioperative care is not a marginal inefficiency but a systemic issue with measurable opportunity costs. They illustrate how reducing low-value preoperative care can redirect financial and human resources to address unmet medical needs. This editorial aims to examine the implications of emerging evidence on low-value preoperative care, using the study by John et al. (2026) as a timely and illustrative example. In doing so, we seek to highlight how persistent patterns of overuse reflect broader systemic challenges in aligning healthcare delivery with patient outcomes and value. We first summarize the key findings of the study, then situate these within the wider global challenge of low-value care, and finally discuss the implications for health system reform, with a focus on advancing quality and patient-centered care. Recently, a consensus definition for low-value care was proposed as care encompassing overuse, misuse and underuse of healthcare services, highlighting the risks that low-value care poses for patients [3]. One critical area, the highest prevalence of overuse, has been reported in use of electrocardiograms, chest X-rays and baseline laboratory tests in low-risk patients having low-risk surgery [2]. This combination of low-value care practices is estimated to account for 20%–40% of total health costs [4]. Key factors driving low-value care are interrelated and complex, including: a “more is better” culture, volume-oriented payment systems, pharmaceutical and medical device commercial approaches, fear of malpractice litigation, biased evidence and knowledge, and inappropriate medical education [5]. Consequently, low-value care has a significant negative impact, undermining allocative efficiency, workforce sustainability, and environmental sustainability. Hence the pressing need for healthcare systems worldwide for de-implementing approaches enabling systematic resource reallocation. While complex, low-value care can be addressed and reduced by prioritizing patient outcomes and quality-driven innovation [6]. A primary task is measuring low-value care, a prerequisite for designing and implementing health systems’ reforms [3]. This task, however, is itself methodologically challenging [3, 7]. There have been initiatives to identify low-value care, e.g. Choosing Wisely [8], which translate evidence-based lists of low-value care into measures and indicators that can be applied in practice. When successfully achieved, transparent outcomes measurement and reporting help tackle inefficient, low-value care and redirect resources to quality health systems, moving beyond service volumes or compliance metrics [6]. However, doing so has not been as successful as hoped. The publication of evidence-based guidelines is not sufficient to change behavior [9], highlighting the need for innovative solutions and leadership. Practice change demands aligned incentives, professional engagement, and governance structures that reward quality rather than volume. In other words, changing mindsets, cultures, systems and practice, which as we know, is a difficult, complex, long-term undertaking. The ultimate purpose of health systems is to improve outcomes for individuals and populations. Reducing low-value care is therefore not solely a cost-containment exercise but is directed at improving quality. For success and impact, quality must be made an explicit priority with aligned objectives at the macro, meso, and micro level, through change-driven leadership, transparent data and innovative solutions [6]. John et al. (2026) identify not merely a “too much testing” problem, but a fundamental misalignment between delivered health services and quality and patient outcomes. The implication is the need for a reorientated health system focused on quality and patient-centered care outcomes. A system that recognizes, i.e. that in low-risk surgery, the right amount of preoperative care will be guided by evidence rather than payment opportunity, professional preference, and/or organizational culture. Moving forward, low-value care reduction ultimately requires ad­dressing organizational systems, clinical cultures, and professional-patient expectations and behaviors. A multicomponent, multilevel approach focused on quality is necessary: adjusting data and payment systems; implementing quality improvement initiatives; targeted education and training; distributing shared decision-making tools and processes; and, at times, individual and team incentives [3]. A critical focus to address low-value care is for health systems to unify measurement frameworks, financing models and governance structures around patient-centered outcomes. John et al. (2026) study exemplifies how administrative data—without additional collection burden–can be enough to disclose misalignment between routine practice, evidence and patient-centered outcomes. The next step for health systems is to embed such measurements within governance and professional norms so that patient-centered care—“right-value” care—becomes the default. A health system that systematically identifies and acts on poor practice with an orientation to measuring and improving patient-centered outcomes, strengthens trust, frees capacity for unmet needs, and reinforces resilience and sustainability. None declared. None declared. The authors affiliated with the World Health Organization are solely responsible for the views expressed in this publication, which do not necessarily represent the decisions or policies of the WHO.