Evidence map›Paper›PMID 29440142›Full record

SynthesisBMJ open2018

Overtesting and undertesting in primary care: a systematic review and meta-analysis.

Jack W O'Sullivan, Ali Albasri, Brian D Nicholson, Rafael Perera, Jeffrey K Aronson, Nia Roberts, Carl Heneghan

Abstract readMeta-AnalysisSystematic Review
PubMed Full text at PMC Publisher
In one paragraph

Synthesis in BMJ open, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 68 papers, 8 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
68citing papers in PubMed, 8 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

68 citing papers in PubMed, 8 syntheses or guidelines pooled it.

  1. Pooled it
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  6. Strategies to reduce the use of low-value medical tests in primary care: a systematic review.The British journal of general practice : the journal of the Royal College of General Practitioners · 2020
    Pooled it
  7. Direct access cancer testing in primary care: a systematic review of use and clinical outcomes.The British journal of general practice : the journal of the Royal College of General Practitioners · 2018
    Pooled it
  8. Pooled it
  9. Article
  10. Article
  11. Article
  12. Addressing the overuse-underuse paradox in healthcare.Medicine, health care, and philosophy · 2025
    Article
  13. Article
  14. Article
  15. Article
  16. The cost of unnecessary test orders: a retrospective study.Malawi medical journal : the journal of Medical Association of Malawi · 2025
    Article
  17. Article
  18. Article
  19. Review
  20. Article

8 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

7 authors.

Jack W O'SullivanCentre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK.
Ali AlbasriCentre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK.
Brian D NicholsonCentre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK.
Rafael PereraCentre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK.
Jeffrey K AronsonCentre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK.
Nia RobertsBodleian Health Care Libraries, University of Oxford, Oxford, UK.
Carl HeneghanCentre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundHealth systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste.

objectiveTo identify overuse and underuse of diagnostic tests in primary care.

designSystematic review and meta-analysis. DATA SOURCES AND ELIGIBILITY CRITERIA: We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care.

resultsWe included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively.

conclusionsThere is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO REGISTRATION NUMBER: CRD42016048832.

Indexed as

AdultDiagnostic Tests, RoutineEchocardiographyEndoscopy, Digestive SystemHumansPrimary Health CareRespiratory Function TestsUnnecessary Proceduresepidemiologyquality in health care

Identifiers

PMID29440142
PMCPMC5829845

What OpenQuestion holds

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LicenceCC BY-NC
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.