 Key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and at the more is better culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure and industry and malpractice policy. This article was authored by Eva W. Verkirk, Simone A. Vandelman, Karen Bourne and others.