Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review.

Importance: Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures. Objectives: To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs. Evidence Review: We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions. Findings: Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders. Conclusions and Relevance: This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

"We're trained to trust our patients": a qualitative study on the general practitioners' trust in patients for colorectal cancer shared care.

BACKGROUND: In a therapeutic partnership, physicians rely on patients to describe their health conditions, join in shared decision-making, and engage with supported self-management activities. In shared care, the patient, primary care, and specialist services partner together using agreed processes and outputs for the patient to be placed at the centre of their care. However, few empirical studies have explored physicians' trust in patients and its implications for shared care models. AIM: To explore trust in patients amongst general practitioners (GPs), and the impacts of trust on GPs' willingness to engage in new models of care, such as colorectal cancer shared care. METHODS: GP participants were recruited through professional networks for semi-structured interviews. Transcripts were integrity checked, coded inductively, and themes developed iteratively. RESULTS: Twenty-five interviews were analysed. Some GPs view trust as a responsibility of the physician and have a high propensity for trusting patients. For other GPs, trust in patients is developed over successive consultations based on patient characteristics such as honesty, reliability, and proactivity in self-care. GPs were more willing to engage in colorectal cancer shared care with patients with whom they have a developed, trusting relationship. CONCLUSIONS: Trust plays a significant role in the patient's access to shared care. The implementation of shared care should consider the relational dynamics between the patient and health care providers.

In a therapeutic partnership, physicians rely on patients to describe their health conditions, join in shared decision-making and engage with supported self-management activities. In shared care, the patient, primary care, and specialist services partner together using agreed processes and outputs for the patient to be placed at the centre of their care. Trust is key to this partnership. However, few studies have explored the physicians' trust in patients and its implications for shared care models. This study aims to explore trust in patients amongst general practitioners (GPs), and the impacts of trust on GPs' willingness to engage in new models of care, such as colorectal cancer shared care. After analysing 25 interview transcripts with GPs, we found some GPs view trust as a responsibility of the physicians, while in others, trust in patients developed over successive consultations based on patient characteristics such as honesty, reliability, and proactivity in self-care. GPs were more willing to engage in colorectal cancer shared care with patients whom they have a developed, trusting relationship. Trust plays a significant role in the patient's access to shared care. The rollout of shared care should consider the relational dynamics between the patient and health care providers.

Overuse of medications in low- and middle-income countries: a scoping review.

Objective: To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions. Methods: We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions. Findings: We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives. Conclusion: Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping review.

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.

Including Information on Overdiagnosis in Shared Decision Making: A Review of Prostate Cancer Screening Decision Aids.

Background. Overdiagnosis is an accepted harm of cancer screening, but studies of prostate cancer screening decision aids have not examined provision of information important in communicating the risk of overdiagnosis, including overdiagnosis frequency, competing mortality risk, and the high prevalence of indolent cancers in the population. Methods. We undertook a comprehensive review of all publicly available decision aids for prostate cancer screening, published in (or translated to) the English language, without date restrictions. We included all decision aids from a recent systematic review and screened excluded studies to identify further relevant decision aids. We used a Google search to identify further decision aids not published in peer reviewed medical literature. Two reviewers independently screened the decision aids and extracted information on communication of overdiagnosis. Disagreements were resolved through discussion or by consulting a third author. Results. Forty-one decision aids were included out of the 80 records identified through the search. Most decision aids (n = 32, 79%) did not use the term overdiagnosis but included a description of it (n = 38, 92%). Few (n = 7, 17%) reported the frequency of overdiagnosis. Little more than half presented the benefits of prostate cancer screening before the harms (n = 22, 54%) and only 16, (39%) presented information on competing risks of mortality. Only 2 (n = 2, 5%) reported the prevalence of undiagnosed prostate cancer in the general population. Conclusion. Most patient decision aids for prostate cancer screening lacked important information on overdiagnosis. Specific guidance is needed on how to communicate the risks of overdiagnosis in decision aids, including appropriate content, terminology and graphical display. Highlights: Most patient decision aids for prostate cancer screening lacks important information on overdiagnosis.Specific guidance is needed on how to communicate the risks of overdiagnosis.

Trends in Prostate Specific Antigen (PSA) testing and prostate cancer incidence and mortality in Australia: A critical analysis.

BACKGROUND: Population trends in PSA testing and prostate cancer incidence do not perfectly correspond. We aimed to better understand relationships between trends in PSA testing, prostate cancer incidence and mortality in Australia and factors that influence them. METHODS: We calculated and described standardised time trends in PSA tests, prostate biopsies, treatment of benign prostatic hypertrophy (BPH) and prostate cancer incidence and mortality in Australia in men aged 45-74, 75-84, and 85 + years. RESULTS: PSA testing increased from its introduction in 1989 to a peak in 2008 before declining in men aged 45-84 years. Prostate biopsies and cancer incidence fell from 1995 to 2000 in parallel with decrease in trans-urethral resections of the prostate (TURP) and, latterly, changes in pharmaceutical management of BPH. After 2000, changes in biopsies and incidence paralleled changes in PSA screening in men 45-84 years, while in men ≥85 years biopsy rates stabilised, and incidence fell. Prostate cancer mortality in men aged 45-74 years remained low throughout. Mortality in men 75-84 years gradually increased until mid 1990s, then gradually decreased. Mortality in men ≥ 85 years increased until mid 1990s, then stabilised. CONCLUSION: Age specific prostate cancer incidence largely mirrors PSA testing rates. Most deviation from this pattern may be explained by less use of TURP in management of BPH and consequent less incidental cancer detection in TURP tissue specimens. Mortality from prostate cancer initially rose and then fell below what it was when PSA testing began. Its initial rise and fall may be explained by a possible initial tendency to over-attribute deaths of uncertain cause in older men with a diagnosis of prostate cancer to prostate cancer. Decreases in mortality rates were many fold smaller than the increases in incidence, suggesting substantial overdiagnosis of prostate cancer after introduction of PSA testing.

Is the risk of cancer in Australia overstated? The importance of competing mortality for estimating lifetime risk.

OBJECTIVES: To calculate lifetime risks of cancer diagnosis and cancer-specific death, adjusted for competing mortality, and to compare these estimates with the corresponding risks published by the Australian Institute of Health and Welfare (AIHW). DESIGN, SETTING: Analysis of publicly available annual AIHW data on age-specific cancer incidence and mortality - for breast cancer, colorectal cancer, prostate cancer, melanoma of the skin, and lung cancer - and all-cause mortality in Australia, 1982-2013. OUTCOME MEASURES: Lifetime risks of cancer diagnosis and mortality (to age 85), adjusted for competing mortality. RESULTS: During 1982-2013, AIHW estimates were consistently higher than our competing mortality-adjusted estimates of lifetime risks of diagnosis and death for all five cancers. Differences between AIHW and adjusted estimates declined with time for breast cancer, prostate cancer, colorectal cancer, and lung cancer (for men only), but remained steady for lung cancer (women only) and melanoma of the skin. In 2013, the respective estimated lifetime risks of diagnosis (AIHW and adjusted) were 12.7% and 12.1% for breast cancer, 18.7% and 16.2% for prostate cancer, 9.0% and 7.0% (men) and 6.4% and 5.5% (women) for colorectal cancer, 7.5% and 6.0% (men) and 4.4% and 4.0% (women) for melanoma of the skin, and 7.6% and 5.8% (men) and 4.5% and 3.9% (women) for lung cancer. CONCLUSION: The method employed in Australia to calculate the lifetime risks of cancer diagnosis and mortality overestimates these risks, especially for men.

Estimating the magnitude of cancer overdiagnosis in Australia.

OBJECTIVES: To estimate the proportion of cancer diagnoses in Australia that might reasonably be attributed to overdiagnosis by comparing current and past lifetime risks of cancer. DESIGN, SETTING, AND PARTICIPANTS: Routinely collected Australian Institute of Health and Welfare national data were analysed to estimate recent (2012) and historical (1982) lifetime risks (adjusted for competing risk of death and changes in risk factors) of diagnoses with five cancers: prostate, breast, renal, thyroid cancers, and melanoma. MAIN OUTCOME MEASURE: Difference in lifetime risks of cancer diagnosis between 1982 and 2012, interpreted as probable overdiagnosis. RESULTS: For women, absolute lifetime risk increased by 3.4 percentage points for breast cancer (invasive cancers, 1.7 percentage points), 0.6 percentage point for renal cancer, 1.0 percentage point for thyroid cancer, and 5.1 percentage points for melanoma (invasive melanoma, 0.7 percentage point). An estimated 22% of breast cancers (invasive cancers, 13%), 58% of renal cancers, 73% of thyroid cancers, and 54% of melanomas (invasive melanoma, 15%) were overdiagnosed, or 18% of all cancer diagnoses (8% of invasive cancer diagnoses). For men, absolute lifetime risk increased by 8.2 percentage points for prostate cancer, 0.8 percentage point for renal cancer, 0.4 percentage point for thyroid cancer, and 8.0 percentage points for melanoma (invasive melanoma, 1.5 percentage points). An estimated 42% of prostate cancers, 42% of renal cancers, 73% of thyroid cancers, and 58% of melanomas (invasive melanomas, 22%) were overdiagnosed, or 24% of all cancer diagnoses (16% of invasive cancer diagnoses). Alternative assumptions slightly modified the estimates for overdiagnosis of breast cancer and melanoma. CONCLUSIONS: About 11 000 cancers in women and 18 000 in men may be overdiagnosed each year. Rates of overdiagnosis need to be reduced and health services should monitor emerging areas of overdiagnosis.

Lifetime risk of prostate cancer overdiagnosis in Australia: quantifying the risk of overdiagnosis associated with prostate cancer screening in Australia using a novel lifetime risk approach.

OBJECTIVES: To quantify the risk of overdiagnosis associated with prostate cancer screening in Australia using a novel lifetime risk approach. DESIGN: Modelling and validation of the lifetime risk method using publicly available population data. SETTING: Opportunistic screening for prostate cancer in the Australian population. PARTICIPANTS: Australian male population (1982-2012). INTERVENTIONS: Prostate-specific antigen testing for prostate cancer screening. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary: lifetime risk of overdiagnosis in 2012 (excess lifetime cancer risk adjusted for changing competing mortality); Secondary: lifetime risk of prostate cancer diagnosis (unadjusted and adjusted for competing mortality); Excess lifetime risk of prostate cancer diagnosis (for all years subsequent to 1982). RESULTS: The lifetime risk of being diagnosed with prostate cancer increased from 6.1% in 1982 (1 in 17) to 19.6% in 2012 (1 in 5). Using 2012 competing mortality rates, the lifetime risk in 1982 was 11.5% (95% CI 11.0% to 12.0%). The excess lifetime risk of prostate cancer in 2012 (adjusted for changing competing mortality) was 8.2% (95% CI 7.6% to 8.7%) (1 in 13). This corresponds to 41% of prostate cancers being overdiagnosed. CONCLUSIONS: Our estimated rate of overdiagnosis is in agreement with estimates using other methods. This method may be used without the need to adjust for lead times. If annual (cross-sectional) data are used, then it may give valid estimates of overdiagnosis once screening has been established long enough for the benefits from the early detection of non-overdiagnosed cancer at a younger age to be realised in older age groups.

Impact evaluation of "Have Fun - Be Healthy" program: A community based health promotion intervention to prevent childhood obesity.

ISSUE ADDRESSED: Childhood obesity is rising in prevalence in Australia. This study aimed to evaluate the impact of the "Have Fun-Be Healthy" (HFBH) intervention, delivered in the Playgroup setting, to generate short term changes in dietary, physical activity and sedentary behaviours of children under 5 years and self-efficacy of parents and primary carers. METHODS: This intervention consisted of eight structured cooking and physical play sessions delivered over a period of 8 weeks by trained facilitators. Pre- and post-intervention data collection was performed using survey questionnaires administered to parents and carers of children under 5 years from low socioeconomic backgrounds recruited through convenience sampling. RESULTS: A total of 640 pre-intervention surveys and 312 post-intervention surveys were returned. The matched response rate was 45.5%. There was an improvement in mean intake of healthy foods and mean physical activity with a decrease in mean intake of unhealthy food and mean screen time in children (P > .05). Following the intervention, parental/carer self-efficacy in promoting healthy eating and limiting screen time of children improved significantly (P < .05). Children's physical activity levels and consumption of healthy foods were positively correlated with parental/carer self-efficacy (P < .01) while screen time and consumption of unhealthy foods were negatively correlated (P < .01). CONCLUSIONS: HFBH intervention was successful in improving the dietary, physical activity and screen time in children and parental self-efficacy. SO WHAT?: Being amongst the first of its' kind in Australia, the findings of this study can have implications for developing and implementing similar future health promotion interventions in comparable settings.

Socioeconomic status and multimorbidity: a systematic review and meta-analysis.

OBJECTIVES: We performed a systematic review to identify, critically appraise and synthesise the existing literature on the association between SEP and multimorbidity occurrence. METHODS: We searched Medline and Embase from inception to December 2014. Where possible we performed meta-analysis to obtain summary odds ratios (ORs), exploring heterogeneity between studies through sub-group analysis. RESULTS: We identified 24 cross-sectional studies that largely reported on education, deprivation or income in relation to multimorbidity occurrence. Differences in analysis methods allowed pooling of results for education only. Low versus high education level was associated with a 64% increased odds of multimorbidity (summary OR: 1.64, 95% CI 1.41 to 1.91), with substantial heterogeneity between studies partly explained by method of multimorbidity ascertainment. Increasing deprivation was consistently associated with increasing risk of multimorbidity, whereas the evidence on income was mixed. Few studies reported on interaction with age or sex. CONCLUSIONS: More methodologically robust studies that address these gaps and investigate alternate measures of social circumstances and environment may advance our understanding of how SEP affects multimorbidity risk. Implications for public health: A deeper understanding of the socioeconomic and demographic patterning of multimorbidity will help identify sub-populations at greatest risk of becoming multimorbid.

Depression, anxiety and risk of hypertension in mid-aged women: a prospective longitudinal study.

OBJECTIVES: The evidence for an association between depression and anxiety and increased hypertension risk is inconsistent. We aimed to investigate the association between each of depression and anxiety and incident hypertension. METHODS: We included women born between 1946 and 1951 from the Australian Longitudinal Study on Women's Health, surveyed triennially from 1998 to 2013, without a history of hypertension at baseline. We defined depression using the Center for Epidemiological Studies Depression scale shortened version 10 and anxiety using self-reported doctor-diagnosis. We related depression and anxiety to incident hypertension, using generalized estimating equations, adjusting for time-varying covariates. RESULTS: Among 9182 women, 2738 developed hypertension during 15-year follow-up. Depression was associated with a 30% increased odds of hypertension [age-adjusted odds ratio (OR) 1.30, 95% confidence interval (CI) 1.19-1.43]. This attenuated and was no longer significant in fully adjusted analyses (OR 1.07, 95% CI 0.96-1.20). Adjusting for BMI alone reduced the association markedly (OR 1.19, 95% CI 1.08-1.31). Anxiety was similarly associated with increased odds of hypertension, but this association became nonsignificant after adjusting for depression (OR 1.12, 95% CI 0.97-1.30). CONCLUSION: The frequently observed association between depression and hypertension may be explained by confounding, whereas comorbid depression may account for the apparent effect of anxiety on hypertension risk. However, further research is needed to determine whether factors such as BMI play a mediating role on a causal pathway between depression and hypertension. Nevertheless, weight and weight gain among women with depression should be closely monitored to reduce potential effects on hypertension risk.