BMJ Global Health: Overdiagnosis and overuse of diagnostic and screening tests in LMICs

16 December, 2022

Mis-use, over-use and under-use of diagnostic and screening tests are all closely associated with a lack of availability and use of reliable healthcare information. Citation, abstract and comment from me below.

CITATION: Albarqouni L, Arab-Zozani M, Abukmail E, et al. Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping reviewBMJ Global Health 2022;7:e008696.


Objective: Overdiagnosis and overuse of healthcare services harm individuals, take resources that could be used to address underuse, and threaten the sustainability of health systems. These problems are attracting increasing attention in low-income and middle-income countries (LMICs). Unaware of any review of relevant evidence, we conducted a scoping review of the evidence around overdiagnosis and overuse of diagnostic and screening tests in LMICs.

Design: Scoping review.

Methods: We searched PubMed, Embase, PsycINFO, Global Index Medicus for relevant studies published until 24 May 2021, with no restrictions on date or language. We categorised included studies by major focus (overdiagnosis, overuse of tests, or both) and main themes (presence or estimates of extent; drivers; consequences and solutions).

Results: We identified 2763 unique records and included 162 articles reporting on 154 studies across 55 countries, involving over 2.8 million participants and/or requests for tests. Almost half the studies focused on overdiagnosis (70; 45.5%), one-third on overuse of tests (61; 39.6%) and one-fifth on both (23; 14.9%). Common overdiagnosed conditions included malaria (61; 39.6%) and thyroid cancer (25; 16.2%), estimated to be >70% in China. Overused tests included imaging (n=25 studies) such as CT and MRI; laboratory investigations (n=18) such as serological tests and tumour markers; and procedures (n=14) such as colonoscopy. Drivers included fear of conflict with patients and expanding disease definitions. Common consequences included unnecessary treatments such as antimalarials, and wasted resources, with costs of malaria overdiagnosis estimated at US$86 million in Sudan in 1 year alone. Only 9% of studies discussed solutions, which included addressing inappropriately lowered diagnostic thresholds and reforming test-ordering processes.

Conclusions Overdiagnosis and overuse of tests are widespread in LMICs and generate significant harm and waste. Better understanding of the problems and robust evaluation of solutions is needed, informed by a new global alliance of researchers and policy-makers.

COMMENT (NPW): The authors conclude there is a need for 'a new global alliance of researchers and policy-makers' to tackle the issue of overdiagnosis and overuse of tests in LMICs. HIFA stands ready to collaborate with such an alliance. Fundamentally this is about the ability to access and apply reliable healthcare information. Every health worker should be able to access and apply reliable healthcare information to be able to assess the pros and cons of diagnostic tests in any given clinical situation.

Best wishes, Neil

Dr Neil Pakenham-Walsh, HIFA Coordinator

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