Reducing unwarranted variation in low-value health care in Norway: description of the NOR programme

Multiple advice-based interventions designed to reduce the use of low-value procedures, i.e. procedures that are medically unnecessary because they provide minimal or no net health benefit, have so far demonstrated limited impact on utilisation rates. The underlying assumption for such initiatives is that increased knowledge, together with data demonstrating unwarranted variation, are sufficient to change clinical practice. Notably, this has not been the case. Numerous studies have documented complex organisational, professional, and patient-level barriers to change. Therefore, we advocate for sharing the experiences from initiatives designed to reduce low-value health care. The Norwegian Operational Group for Reassessment (NOR) Programme is a Norwegian national initiative, launched by the Chief Executive Officers of the Norwegian Regional Health Authorities and governed by the Centre for Clinical Evaluation and Documentation, to reduce the use of low-value procedures. Selection criteria included: (i) international designation as low-value care (e.g., Choosing Wisely, Evidence-Based Intervention Programme), (ii) moderate to high patient risk, (iii) high cost, and (iv) high volume and geographical variation. Based on these criteria, three initial targets were identified: (a) arthroscopic treatment of acromial impingement and repair of non-traumatic rotator cuff rupture; (b) upper gastrointestinal endoscopy in patients aged < 45 years; and (c) invasive coronary angiography in patients with stable coronary artery disease. Expert groups for each area were established in 2024 and have produced consensus-based recommendations describing a set of multifaceted interventions to reduce overuse. This manuscript presents those recommendations and shares early experience from implementation within the NOR Programme.