Article Text

Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping review
1. Loai Albarqouni1,
2. Morteza Arab-Zozani2,
3. Eman Abukmail1,
4. Hannah Greenwood1,
5. Thanya Pathirana1,3,
6. Justin Clark1,
7. Karin Kopitowski4,
8. Minna Johansson5,6,
9. Karen Born5,
10. Eddy Lang7,
11. Ray Moynihan1
1. 1 Institute for Evidence-Based Healthcare (IEBH), Bond University, Gold Coast, Queensland, Australia
2. 2 Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
3. 3 School of Medicine and Dentistry, Griffith University, Sunshine Coast, QLD, Australia
4. 4 Directora Departamento de Investigación, Instituto Universitario Hospital Italiano, Argentina, Argentina
5. 5 Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg University, Gothenburg, Sweden
6. 6 Cochrane Sustainable Healthcare, Uddevalla, Sweden
7. 7 Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
1. Correspondence to Dr Loai Albarqouni; lalbarqo{at}bond.edu.au

## Abstract

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).

## Discussion

To our knowledge, this is the first scoping review of its kind, summarising evidence for the problems of overdiagnosis and overuse of tests in LMICs. We analysed 154 studies from 55 different LMIC countries, predominantly middle income, with most reporting on the extent of these problems and their consequences for overtreatment and unnecessary healthcare services, few investigating drivers, and even fewer, potential solutions. The available evidence comes largely from observational studies, with a significant minority from randomised controlled trials. Our findings provide strong evidence to encourage efforts such as Choosing Wisely and Preventing Overdiagnosis to continue to expand activities within LMICs, and for national and global stakeholders to devote increased attention to addressing the harms and waste of unnecessary healthcare services.

The review has shown that overdiagnosis and overtreatment of thyroid cancer and malaria have attracted widespread attention within LMIC settings, although these are just 2 of 38 conditions covered in our review. Estimated rates of overdiagnosis of 50% of thyroid cancer diagnosed among women in parts of India,43 and over 75% of men and women in China25 demand urgent responses. An international analysis of the mortality and incidence of thyroid cancer in 25 population-based registries (from both high-income and LMICs) showed that the pattern of overdiagnosis and variations in the rates of incidence of thyroid cancers are very similar among LMICs compared with high-income countries.23 This might reflect shared common drivers and potential solutions to the problem of overdiagnosis and overuse of tests between LMICs and high-income countries. Overuse of a wide range of tests including CT and MRI scans, blood tests and endoscopies also emerged as a common problem, causing harm and waste in limited-resource settings. Two recent studies, from Brazil44 and China45 identified rates of inappropriate ordering of tumour markers, both in excess of 50%, underscoring the need for better regulation of the use of emerging medical technologies. A small number of qualitative studies identified drivers of these problems including fear of litigation and conflicts with patients, financial incentives, and expanding disease definitions.30 32 The few studies exploring solutions tended to focus on evaluating new diagnostic processes designed to reduce overdiagnosis, such as the rapid diagnostic tests for malaria, or administrative reforms to reduce overtesting.

Our review has some important limitations and strengths. Given the necessary breadth of a scoping review, we have included studies using a range of definitions of the key concepts of overdiagnosis and overuse of tests. For example, as discussed in box 1, some proportion of what is described as overdiagnosis in some malaria studies is clearly misdiagnosis. But whether the problems meet strict and changing academic definitions are far less important than tackling what are clear and widespread problems with diagnostic processes that cause harm and waste via overtreatment of malaria, and undertreatment of undiagnosed conditions. Another limitation arises from excluding studies which did not fully meet our inclusion criteria, but raise valuable concerns about potential overdiagnosis or misdiagnosis across a range of infectious and non-infectious conditions, including HIV,46 cervical abnormalities,47 appendicitis48 and entamoeba histolytica,49 suggesting the review findings may be underestimating the existence of these problems in LMICs. A final limitation arises from this being a broad scoping review, with no critical appraisal of the quality of included studies. Strengths of this review are found in its comprehensive search with no language restrictions, adherence to gold-standard methodology, including paired independent screening and involvement of review authors from LMIC settings.

The results of this scoping review in LMICs on overdiagnosis and overuse of tests have added to knowledge about the nature and extent of these problems, but have also identified important gaps, which can inform both research and action agendas. On the research front, there is a clear need for national and global estimates of the extent of harm19 and cost of waste from overdiagnosis and overuse of tests, to inform both policy and wider social responses. This scoping review has also reinforced the need for better guidance on optimum methods for investigating overdiagnosis. Development and evaluation of both narrow and broad solutions to reduce overdiagnosis and overuse of tests are clearly needed, using randomised trials where feasible. Different medical conditions will require different approaches, with solutions tailored to specific drivers. For example, the overdiagnosis of malaria by compassionate professionals will demand very different responses to more commercially driven screening and treatment of benign thyroid tumours. On the action front, this review will also inform the development of a new global network of researchers and health policy workers interested in advancing this agenda. We plan to contact all authors of included studies inviting them to join an international community of practice, planning meetings and research collaborations. Alongside the challenges of confronting these complex and counterintuitive problems are opportunities to share data and learn from each other’s experience, across both high-income countries and LMICs. There are already movements, such as Choosing Wisely and Quaternary Prevention,50 51 building such networks. And as flagged above, working with colleagues from LMICs, we intend to conduct a seperate scoping review of the evidence about the overuse of medications in LMICs.

The WHO has observed that the global move towards universal health coverage is making the problems of overdiagnosis and overuse of healthcare services more pressing,14 15 and a recent World Bank report makes clear that providing ‘high-quality health services’ means minimising harm and waste.52 To achieve universal health coverage, especially in the post-pandemic recovery, there is a clear need for health systems to focus more on what matters most, and direct resources to where they are most needed. Tackling underuse of evidence-based healthcare services,2 including diagnostic and screening tests, can only benefit from an enhanced effort to reduce overdiagnosis and overuse. Addressing medical excess and prioritising higher-value healthcare are becoming increasingly important global priorities.

## Data availability statement

Data are available on reasonable request.

Not applicable.

• ## Supplementary Data

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

## Footnotes

• Handling editor Seye Abimbola

• Twitter @loaialbarqouni, @EAbukmail, @hannahgrnwd, @karinkopitow, @minnajohansson1, @bornk, @EddyLang1, @raymoynihan

• Contributors LA and RM conceived the idea and all the authors helped in the study design. LA, MA-Z, EA, HG, TP and RM assessed study eligibility and extracted data. LA and RM analysed the data and wrote the first draft of the manuscript. All authors contributed to the interpretation and subsequent edits of the manuscript. LA and RM had full access to all of the data in the study and takes responsibility for the data and the integrity of the study. LA is the guarantor.

• Funding None specific for this study. LA is supported by by a research fellowship funded by the National Health and Medical Research Council (NHMRC Investigator grant, grant No 2008379). RM is supported by a research fellowship funded by the National Health and Medical Research Council (NHMRC, grant No 1124207) and a chief investigator on a Centre for Research Excellence (grant No 1104136) and have helped organise Preventing Overdiagnosis conferences. All other authors declare no competing interests.

• Disclaimer The funders had no role in the design, conduct, reporting, or dissemination plans for this study.

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• Competing interests None declared.

• Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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