There is an increasing interest in divesting activities, giving rise to several initiatives both academic and governmental to identify and address one of the problems of health systems. In 2013 the Spanish Atlas of Variability in Clinical Practice (VPM) in collaboration with the Spanish Network of Health Technology Assessment (HTA) Agencies started a project with the purpose of providing elements to support a national strategy aimed at minimizing the use of doubtful procedures in the Spanish National Health System (1).

The identification, selection and definition of low added value procedures and the determination of the most cost-effective alternatives were carried out jointly between the AtlasVPM group and the HTA agencies of Andalusia (AETSA), Catalonia (AQUAS), Galicia (Avalia-t), Basque Country (Osteba), Madrid (UETS) and Aragon (IACS). The process consisted of the following phases: (i) Literature review; (ii) Preliminary list of procedures of dubious value; (iii) Analysis of feasibility and construction of the indicators (variability); and (iv) Empirical validation of the defined indicators. Different lists and sources of evidence were used to identify the procedures and evidence that support their low-value.

The synthesis of the evidence gave rise to an initial list of fifty-nine procedures of doubtful value that could be classified as: obsolete or outdated procedures in comparison to more effective / cost-effective alternatives (n = 31), procedures of doubtful value when used outside their main indication (n = 17) and procedures for which the evidence around effectiveness was still insufficient (n = 11). With the advice of clinical experts and coders, the original list was reduced to seventeen procedures and after some adjustments to thirteen.

Identifying procedures of low-added value is a complex task and is context dependent. Literature could be useful to identify a preliminary list but the analysis of the clinical practice, its variability and reasons that justify it are required to determine which procedures are good candidates for disinvestment.