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

Loai Albarqouni, Eman Abukmail, Majdeddin MohammedAli, Sewar Elejla, Mohamed Abuelazm, Hosam Shaikhkhalil, Thanya Pathirana, Sujeewa Palagama, Emmanuel Effa, Eleanor Ochodo, Eulade Rugengamanzi, Yousef AlSabaa, Ale Ingabire, Francis Riwa, Burhan Goraya, Mina Bakhit, Justin Clark, Morteza Arab-Zozani, Suzanna Alves da Silva, C. S. PrameshVerna Vanderpuye, Eddy Lang, Deborah Korenstein, Karen Born, Stephen Tabiri, Adesoji Ademuyiwa, Ashraf Nabhan, Ray Moynihan

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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. 


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. 


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.

Original languageEnglish
Article number2342215
Pages (from-to)1-21
Number of pages21
JournalJAMA network open
Issue number11
Publication statusPublished - 1 Nov 2023


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