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

BMJ Open. 2018 Feb 11;8(2):e018557. doi: 10.1136/bmjopen-2017-018557.


Background: Health 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.

Objective: To identify overuse and underuse of diagnostic tests in primary care.

Design: Systematic 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.

Results: We 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.

Conclusions: There 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.

Keywords: epidemiology; quality in health care.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Adult
  • Diagnostic Tests, Routine / statistics & numerical data*
  • Echocardiography / statistics & numerical data
  • Endoscopy, Digestive System / statistics & numerical data
  • Humans
  • Primary Health Care / organization & administration*
  • Respiratory Function Tests / statistics & numerical data
  • Unnecessary Procedures / statistics & numerical data*