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Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

Abstract

Background

Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

Methods

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

Results

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

Conclusions

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

Systematic review registration: PROSPERO: CRD42020208072.

Peer Review reports

Background

The use of health care and health care expenditures are increasing in most countries [1]. According to the Organization for Economic Co-operation and Development (OECD) 10–34% of health service spending is inappropriate and wasteful use of health care resources [2]. Diagnostic imaging is a health care resource aiding the physician in identifying correct diagnoses and administering the right treatment for the right patient at the right time [3]. However, imaging services can also be inappropriately used or be of low clinical value. While inappropriate imaging is characterized by not being in accordance with professional norms and guidelines, low-value care is defined as services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary cost to patients, or waste limited healthcare resources. Diagnostic imaging would be of low-value when the examination has little or no impact on the management of the individual patient, thus in a societal perspective increasing costs and constituting an unnecessary risk to patients due to exposure to ionizing radiation [4] and/or contrast media [5]. Earlier research found that 20–50% of radiological examinations are overused, however, this rate varies between and within countries [2, 6,7,8]. Recommendations and guidelines such as the National Institute for Health and Care Excellence’s (NICE’s) “Do-not-do list,” iRefer, iGuide and the international Choosing Wisely campaign have been introduced to reduce overutilization in health care and reduce low-value care, including diagnostic imaging [9,10,11]. So far, the impact of such efforts is reportedly low, as patient expectations of advanced diagnostic tests, lack of knowledge among health care professionals on the right use of imaging, established clinical practice, fear of malpractice, and fee-for-service reimbursement systems continue to drive the use of low-value care [6, 12,13,14,15,16]. Knowledge about low-value imaging in terms of characteristics, quantities and contexts is warranted to enable adequate prioritizing of resource utilization and designing de-implementation initiatives. A recent systematic review previously estimated the prevalence of low-value diagnostic testing, which included some radiological services, but did not provide a complete overview of which diagnostic imaging examinations that may be regarded as low-value [17]. Therefore, the objective of this scoping review was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations.

Methods

A scoping review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews [18]. The protocol for this scoping review is registered on the PROSPERO website (CRD42020208072). Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from January 2010 to September 9, 2020. The search strategy was developed in Medline-Ovid (Table 1) and adapted for the other databases with assistance/support from librarians. Terms were built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization with text word synonyms of these terms, and more specific terms not having a Mesh term. Language filters were used to include articles written in English, German, Dutch, Danish, Norwegian, and Swedish. Animal studies were excluded. The complete search strategy is available in Additional file 1.

Table 1 Search strategy in Medline (Ovid)

The search was expanded through a snowballing technique of hand-searching the reference lists of articles included following full-text screening.

Selection of records

The records were archived using Thomson Reuters EndNote X9.3.3 library and duplicates were removed. All remaining records were transferred to Rayyan QCRI [19] where titles and abstracts were screened by EK, ERA, LvB-V, FC, and BMH for eligibility; 10% of citations were screened by two of the authors as quality assurance. Full-text screening was completed by EK, ERA, AMK LvB-V, LJJS and BMH after a calibration meeting for quality assurance. Disagreements with regards to inclusion or exclusion were resolved through discussion and consensus among the authors.

Eligibility criteria

The inclusion and exclusion criteria are presented in Table 2. In brief, empirical studies, including randomized controlled trials (RCTs), non-randomized controlled trials, cohort studies, descriptive qualitative studies, case studies, mixed-methods studies, and multi-methods studies assessing the value of radiological examinations for all patient groups were included.

Table 2 Inclusion and exclusion criteria

Data extraction and synthesis

Data of the included studies were extracted using a summary table consisting of the following variables: author and year, country, design/methods, population, clinical setting, medical condition, low-value practice, reason for being low-value, alternative to low-value practice, and extent of use (when applicable). EK, ERA, AMK, and BMH extracted data after a calibration meeting where 10 publications were discussed for quality assurance. Narrative synthesis of included articles was completed. Articles were first categorized by adult or pediatric, the imaging modality, type of radiological examination evaluated, and the anatomical area imaged.

Results

The electronic database search identified 39,986 records (findings are documented in Additional file 1) and 17,429 duplicates were removed. A total of 22,557 records were screened for titles (and abstracts) in Rayyan QCRI [19] excluding 21,907 records. Through additional searches and snowballing, 44 additional records were found, resulting in 694 articles for full-text assessment. Following full-text screening 324 articles were excluded; an overview of the excluded articles and the reason for exclusion is presented in Additional file 2. Ultimately, 370 studies were included in the final synthesis. A PRISMA flow diagram of the screening and selection process is presented in Fig. 1.

Fig. 1
figure 1

PRISMA flow diagram of the selection process of articles

Among the 370 included studies, 84 low-value imaging examinations were identified. Studies were conducted in 35 different countries, with most from the United States (n = 215) and Europe (n = 78). In-hospital imaging was the most common clinical setting (> 65%). Fourteen different study designs were employed among the included studies; most studies were designed as retrospective chart reviews (n = 262), cohort studies (n = 39), and cross-sectional studies (n = 19). Three hundred and eight studies included adult patients, 60 studied pediatric populations, and 2 studies included both adults and children. The characteristics of the included articles are provided in Additional file 3.

Identified low-value imaging examinations

Low-value diagnostic imaging in adults was evaluated in 264 studies. Across all imaging modalities, low-value use of computed tomography (CT), magnetic resonance imaging (MRI), and X-ray were most frequently reported.

Outcomes measured for identifying low-value examinations varied across the studies and the most common were diagnostic yield (n = 213), and impact or change in treatment or management (n = 137). Importantly, the examinations defined as low-value were dependent on the clinical symptoms of patients e.g. a lumbar spine MRI is only valuable when the patient present with red flag symptoms.

In the following sections, results are stratified by body areas (neurologic (central nervous system [CNS]), thoracic, musculoskeletal, abdominopelvic, vascular, whole body, breast, cardiac, and ear, nose, and throat, and neck imaging) and population type (i.e., adult versus pediatric population).

Low-value radiological examinations in adults

Neurologic imaging

Low-value imaging of the brain was explored in 49 studies [20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66]. Specifically, routine use of head CT or repeat head CT in minor head injury and brain MRI were reported to be low-value for many clinical indications and conditions. The reason for being low-value was either low diagnostic yield where the majority of scans were reported to have no relevant findings, or a low rate in change of management for patients examined. To reduce the use of low-value neurologic imaging the studies indicated that the scan should be warranted based on patient symptoms rather than routine. Details are presented in Table 3.

Table 3 Overview of low-value imaging of the head and brain with reported outcome and suggested practice

Further, low-value imaging examinations of the cervical spine was identified in eleven studies [67,68,69,70,71,72,73,74,75,76,77] including routine imaging in trauma and routine follow-up after surgery in patients without symptoms (Table 4).

Table 4 Reported imaging of the cervical (c)-spine with low-value to patients

Thoracic imaging

Thirty-eight studies reported chest X-rays to be low-value, while four studies reported on low-value use of chest CT [78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117]. Of these, eighteen reported on chest X-rays in follow-up after procedures known to cause pneumothorax, where the X-ray did not change management in patients without symptoms [94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112]. Further, routine chest X-ray was found to not change patient management when used as a pre and post op screening, at hospital admission, in medical check-ups, or in staging of cervical and breast cancer. Repeat chest X-ray in trauma and ICU patients was found to be low-value and clinical symptoms should be used as an indicator to do an X-ray [78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93, 113, 118,119,120]. In CT, low-value examinations were found in emergency department patients, pleural effusion, and in staging of low-grade breast cancer as the diagnostic yield is low [114,115,116]. Further, repeat chest CT in Covid-19 patients showing clinical improvement was shown to be of low-value [117]. Details are presented in Table 5.

Table 5 Reported low-value thoracic imaging

Musculoskeletal imaging

Spine and hip or pelvis

The most commonly reported low-value procedures in musculoskeletal imaging was for low back pain [121,122,123,124,125,126,127,128,129,130]. Ten studies demonstrated that X-ray, CT and MRI have a low impact on the treatment of patients without red flags, and 58.7% of MRI scans were negative [121,122,123,124,125,126,127,128,129,130,131], imaging for pain in the rest of the spine was also shown as low-value [131]. In addition, change in management were only seen in < 1% of routine post-op X-rays after cervical (c)- or lumbar (l)-spine fusion [132,133,134]. Another study found that even though 93% of the referrals for lumbar MRI were appropriate according to guidelines, only 13% of the scans showed actionable findings [125]. In cases of pelvic fracture or trauma, routine pelvic X-ray had a low impact on treatment. The same was shown for MRI or CT in pelvic ring fracture [91, 135,136,137]. In hip fracture and hemiarthroplasty, routine post-op X-ray of the hip was low-value for patients without symptoms [138, 139]. One study showed that MRI is low-value in patients with hip pain when an X-ray is already acquired [140]. Details are presented in Table 6.

Table 6 Overview of low-value imaging in the spine, pelvis, and hip
Upper and lower limb

The second most common studied musculoskeletal low-value examination was MRI in knee pain without red flags, reported in eight studies [121, 141,142,143,144,145,146,147]. In addition, MRI of acute Achilles tendon rupture, X-ray of adjoined joints in ankle fracture, and CT of lower extremities stress fractures were also reported as low-value examinations [148,149,150]. X-ray of the knee changed management in 0–0.7% of patients after ligament reconstructions, tibia plateau fixation, and partial or total knee arthroplasty [151,152,153,154,155,156]. In the upper limb, shoulder MRI in patients with shoulder pain or rotator cuff tear had a low impact on treatment [157,158,159]. X-ray of the shoulder in atraumatic shoulder pain or frozen shoulder had a low impact on clinical management [160, 161]. Further, orthopedic trauma, post-op, or post-splinting X-ray gave little to no change in management [162,163,164,165,166,167,168,169]. MRI of the wrist in ligamentous injury changed the surgical plan in 28% of patients and was thus low-value for many patients [170]. On general use of imaging in the musculoskeletal system, four studies showed that skeletal CT for peri-articular fractures (post-op) [171], and long bone cartilaginous lesions (also MRI) [172] were of low-value. Details are presented in Table 7.

Table 7 Overview of low-value imaging in upper and lower limbs

Abdominopelvic imaging

In abdominopelvic imaging, eighteen studies reported imaging with low-value in typical emergency or general medicine conditions [175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191]. X-rays for abdominal pain and upper gastrointestinal imaging (UGI) for reflux resulted in a change in management in only 4% of patients and is often of poor diagnostic quality [187,188,189]. In acute pancreatitis, < 1.2% of CT and MRI examinations yielded relevant findings [175,176,177,178]. Low-value imaging related to surgery or other invasive procedure in the abdomen was reported in seven studies [192,193,194,195,196,197,198]. Contrast esophagogram had a low impact on treatment in suspected esophageal perforation, and anastomotic leaks after esophagectomy [195, 197, 198]. In addition, staging of cancer using a different kind of MRI or CT in the abdominal/pelvic area was described as low-value in six studies for various types of cancer [199,200,201,202,203]. In urology, abdominal CT in urolithiasis had a low impact on the treatment of patients with self-limiting episodes or at follow-up [190, 204,205,206]. Renal ultrasound in new-onset acute kidney injury to screen for hydronephrosis led to changes in management in just 1.8% of patients in one study [207]. In addition, retrograde urethrography in penile fracture had a low impact on treatment in patients without hematuria or urethrorrhagia [208]. An overview of low-value imaging in abdominopelvic imaging is given in Table 8.

Table 8 Overview of low-value abdominal imaging

Vascular imaging

The two most reported low-value vascular imaging examinations were CTA of the chest in patients with low risk of pulmonary embolism (7 studies) and ultrasound in patients with low risk for deep venous thrombosis (5 studies). Negative result was demonstrated in 97% of examinations [210,211,212,213,214,215,216,217,218,219,220,221]. Further, CTA of the abdominal aorta after endovascular aneurysm repair (EVAR) in patients without endoleak 1 month after the EVAR procedure, was identified as low-value [222,223,224]. Ultrasound was reported to be better as surveillance for EVAR patients as ultrasound increased the negative predictive value to 97.6% [222,223,224]. In addition, CTA was shown to be of low-value in patients with blunt vertebral artery injuries and vascular injuries of the lower limbs [225, 226]. Details are presented in Table 9.

Table 9 Reported vascular imaging with low-value to patients

Whole body imaging

Whole body imaging examinations were identified as low-value in trauma and oncology in six studies. Whole body scanning in trauma should be made only when clinically indicated [227,228,229,230,231,232]. In addition, one study identified CT in soft tissue infections as low-value, with the exception of intra-abdominal abscesses [233]. In oncology, whole body imaging used for staging and follow-up was identified as low-value in 18 studies [58, 234,235,236,237,238,239,240,241,242,243,244,245,246,247,248,249,250]. Details on low-value whole body imaging in oncology is presented in Table 10.

Table 10 Overview of identified low-value whole body imaging for staging and follow-up in oncology

Breast imaging

In breast cancer follow-up, mammography or MRI of the breasts less than 1-year after treatment were described as low-value [255,256,257,258,259,260,261,262]. Follow-up of benign breast tumors with short intervals showed only 0–0.5% identified malignancy in three studies, thus low-value to the majority of patients [260,261,262]. According to one study [263] on male patients only, 0.9% of breast ultrasound or mammography found malignancy. Details are presented in Table 11.

Table 11 Overview of identified low-value breast imaging

Cardiac imaging

Stress imaging such as myocardial perfusion imaging (MPI) and echocardiography were described as low-value in low risk patients, and patients with more than one risk factor for cardiac disease [264, 265]. In patients with infective endocarditis, only 10% of the findings in FDG PET/CT of the heart led to changes in treatment [266]. Routine transthoracic echocardiography in acute ischemic stroke patients had relevant findings in 38% of patients, however only 8.5% of patients had additional work-up [267]. Elective coronary angiography investigating coronary heart disease had relevant findings in 40% of patients in one study [268]. Yet another study found that during coronary angiography left ventriculography is of poor quality [269]. An overview of low-value cardiac imaging is given in Table 12.

Table 12 Overview of identified low-value examinations in cardiac imaging

Neck and ear, nose, and throat imaging

Post-operative thyroid cancer ultrasound was found to be low-value as 98% of the scans were negative [270] and the risk for relapse is small [271]. Furthermore, increased use of ultrasound uncovered more benign and low-risk cancers [272, 273]. Radioactive iodine scanning found 17% concordant findings with earlier examinations. Thus, fine needle aspiration should be used in diagnostics instead of imaging [274]. Thyroid ultrasound as follow-up after lobectomy found tumor or recurrence in only 1.5% of patients [275]. According to one study, in patients with secondary hyperparathyroidism routine pre-op Tc-99 m-sestamibi scans are unnecessary as nodules are found during surgery [276].

X-ray and CT of the sinuses in acute rhinosinusitis did not change patient management [277].

In patients with facial fractures, X-ray and CT was identified as low-value in five studies [278,279,280,281,282], as imaging did not change the management of the patient. One study introduced the use of ultrasound combined with an X-ray, instead of CT in zygomatic arch and mandibular fractures [281]. Another study described MRI of the face for juvenile ossifying fibroma as low-value [283].

Imaging of templar bones was described as low-value in patients with chronic Eustachian tube dysfunction and pre-op for cochlear implants [284, 285]. Details are presented in Table 13.

Table 13 Overview of low-value imaging in Neck and ear, nose, and throat imaging

Low-value imaging examinations in children

The use of low-value imaging in pediatric patients was reported in 62 studies presented in Table 14 [168, 286,287,288,289,290,291,292,293,294,295,296,297,298,299,300,301,302,303,304,305,306,307,308,309,310,311,312,313,314,315,316,317,318,319,320,321,322,323,324,325,326,327,328,329,330,331,332,333,334,335,336,337,338,339,340,341,342,343,344,345]. The most frequently reported low-value examinations were CT and MRI of the head/brain, CT and X-ray related to trauma, chest X-ray, and musculoskeletal X-rays in fracture follow-up.

Table 14 Overview of imaging identified as low-value in pediatrics sorted by body system

The quantity in use of low-value examinations

The proportion of low-value examinations varied greatly in the 103 included studies reporting proportion. Seven studies explored low-value imaging in adults on an overarching level with several medical conditions and modalities, showing an overall rate of low-value imaging of 2–31% [346,347,348,349,350,351,352].

Quantity of low-value imaging in adults

The proportion of low-value imaging examinations in specific body areas differed from 4 to 100% (86 studies], and varied both between and within different countries and clinical settings. The results are presented in Fig. 2 [20,21,22,23, 26,27,28,29, 35, 40,41,42, 54, 64, 68, 69, 122, 123, 125, 127,128,129,130, 140, 141, 143, 145,146,147, 157,158,159, 172,173,174, 176, 177, 179, 182, 190, 210, 211, 213, 215, 216, 229, 242, 252, 277, 284, 353,354,355,356,357,358,359,360,361,362,363,364,365,366,367,368,369,370,371,372,373,374,375,376,377,378,379,380,381,382,383,384,385,386,387]. From these studies, imaging examinations with a high proportion of low-value examinations (more than 50% inappropriate use reported) was: Head CT (routine and repeat), routine trauma scan, MRI in musculoskeletal pain, dual-energy x-ray absorptiometry (DEXA) in low risk patients or low interval DEXA follow-ups, echocardiography, carotid imaging, chest X-ray, X-ray in acute rhinosinusitis, CTA in pulmonary embolism, early-stage breast cancer staging, acute pancreatitis, and special imaging for pre-op templar bone CT in cochlear implantation, and CT/MRI in long bone cartilaginous lesions. In addition, one study reported a sevenfold increase in knee MRI, while there was a reduction in knee arthroscopy [145].

Fig. 2
figure 2

Overview of proportion of low-value examinations in different patient complains/diagnosis. The blue bar represents the minimum rate and the combined blue and orange bar represents the maximum inappropriate rate

Quantity of low-value imaging in children

In pediatrics the use of low-value examinations varied between 3.6 and 93.7% (11 studies) [286, 297, 299, 301, 314, 315, 320, 321, 356, 388, 389]. Abdominal CT in appendicitis (3.6%), repeat CT in trauma patients (5%) and C-spine CT in cervical spine injury (13%) were the least over-used examinations. Head CT (50–93.7%), CT scan in case of blunt abdominal trauma (18–80%) and pretransfer CT in trauma patients (66%) were the low-value examinations most used.

Discussion

In summary, through this scoping review, we found 84 different low-value imaging examinations performed among both adult and pediatric populations, for all imaging modalities, and body areas. Several of these examinations already have established referral criteria or have recommendations against them in the Choosing Wisely list, however this review show that these are still being used in clinical practice, and more examinations might need referral guidelines. The most commonly practices reported as low-value was head CT in several clinical queries (especially related to minor head injury [20,21,22,23,24,25,26,27,28,29,30,31,32,33, 36, 37, 40,41,42,43,44,45,46,47,48,49,50,51,52,53, 55, 56, 286,287,288,289,290,291,292,293]), chest X-ray for routine checkup or follow-ups [78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113, 118,119,120, 339,340,341,342,343], trauma CT in patients without clinical symptoms or as repeat scans [227,228,229,230,231,232, 287, 314,315,316,317,318,319,320,321,322], and skeletal X-rays in non-traumatic pain or in fracture follow-ups [132, 138, 139, 151,152,153,154,155,156, 160,161,162,163,164,165,166,167, 169, 323,324,325,326,327,328,329,330,331,332,333,334,335,336,337]. The following were the most frequently reported low-value examinations: imaging in low back pain [121,122,123,124,125,126,127,128,129,130,131] and knee MRI without red flags [121, 141,142,143,144,145,146,147], staging and follow-up in several types of cancer (X-ray, CT, MRI and nuclear medicine) [58, 116, 172, 199,200,201,202,203, 209, 234,235,236,237,238,239,240,241,242,243,244,245,246,247,248,249,250,251,252,253,254,255,256,257,258,259,260,261,262], abdominal CT in self-limiting episode of suspected urolithiasis [190, 204,205,206], chest CTA [210,211,212,213,214,215,216] and ultrasound lower limb veins in patients with low risk of thrombosis [217,218,219,220,221] were most prominent among adult populations. When analyzing the extent in use of low-value imaging additional examinations were identified; low interval DEXA screening, echocardiography in patients with low risk of cardiac disease, carotid imaging in syncope, X-ray in rhinosinusitis, and MRI for pain in the hip or upper extremities [140, 157,158,159, 173, 277, 365, 366, 369, 373, 376].

The variation in the proportion of low-value imaging was large (2–100% inappropriate or unnecessary examinations) and varied between studies of the same examination. There is no obvious threshold in proportion for when to define examinations as low-value. Even though the examinations found in this review are low-value on a group level, certain patient sub-groups or individual patients could have clinical findings justifying the use of imaging. However, in several studies there were identified a rate of ≥ 90% inappropriate imaging examinations. This provides a reason for altering the utilization of these examinations in practice. We found this to be the case in: repeat head or routine trauma CT, echocardiography, MRI in hip, knee and upper extremity pain, CT/MRI in acute pancreatitis, and pre-op templar bone CT in cochlear implantation [40,41,42, 54, 140, 141, 143, 145,146,147, 173, 176, 177, 229, 284, 357, 369, 388].

Our review found additional examinations that are potentially low-value to the examinations presented in the Choosing Wisely list [17, 390]. Additionally, we report the extent of low-value imaging. Our additional findings merit further investigation, including chest X-ray after invasive lung procedures such as CVC placement, chest tube placement/removal, biopsies, and other procedures [94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112, 339,340,341], musculoskeletal follow-ups after fractures or invasive procedures, MRI and X-ray in atraumatic shoulder or upper-extremity pain [138, 139, 151,152,153,154,155,156, 160,161,162,163,164,165,166,167, 169, 173, 323,324,325,326,327,328,329, 334, 336] and staging and follow-up procedures in cancers other than breast, cervical, prostate, and lymphoma [58, 172, 199, 202, 203, 209, 235,236,237, 239,240,241, 243,244,245, 247,248,249]. Hence, while we confirm previous findings, we also add new findings to the literature. Not all examinations in the Choosing Wisely list were included in this in this review such as cardiac imaging in asymptomatic patients or head CT in patients with sudden hearing loss [390]. This could be caused by the search being incomplete (for instants excluding screening programs), evidence of their low-value was given before 2010 or that some of the Choosing Wisely recommendations were based on clinical experience rather than research reports.

There are many ways to measure low-value imaging, including diagnostic yield, diagnostic accuracy, and impact/change in treatment or management, where diagnostic yield (n = 213) and change in patient management (n = 137) were most common. By applying the Fryback and Thornbury value model as stated by Brady et al. [391], measures of change in patient management and trends in imaging and related treatments, seems a better way to identify low-value imaging, rather than measuring diagnostic accuracy [391].

This scoping review has strengths and limitations in its methods. Although the search in databases was systematic and exhaustive, the cut-off was set at 2010, which excluded examinations identified as low-value imaging or adopted to clinical practice before 2010. Due to the large number of citations retrieved from the database searches, a wide range of inconclusive studies, studies identifying conditional low-value imaging, and articles reporting clinical practice guidelines were excluded. Hence, a wide range of supportive studies were excluded as the inclusion criteria were strict. Therefore, it is likely that there are several studies of low-value examinations that are not included in this review. Accordingly, the excluded studies in Additional file 2 may provide useful information for those who want to pursue specific examinations. The quality of included studies was also not assessed; it is likely that the included studies were of variable quality, limiting the strength of the conclusions made in this review. While the strict inclusion criteria may to some extent compensate for the lack of study quality assessment, quality assessment is not required [392] as the purpose of a scoping review is to identify and map the available evidence. While this review provides a valuable overview of identified low-value imaging, especially useful for clinicians and policymakers to be able to take actions to reduce overuse of diagnostic imaging. However, contextual assessment is needed before changing clinical practice. In addition, the risk of ionizing radiation or contrast media has not been considered in this analysis, this would be interesting issues to consider in later studies. There is also need for research on barriers and facilitators for reducing low-value imaging care to assess where to target policy changes, guidelines, and clinical practice.

Conclusions

In this study, we provide a comprehensive list of low-value radiological examinations for both adults and children. Our overview reaches beyond earlier published lists and adds information on the quantity of low-value imaging utilization, which reportedly varied from 2 to 100% among included studies. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after chest interventions, fracture follow-up and cancer staging, or follow-up were the most frequently identified low-value imaging examinations. This overview can be of great value for clinicians, policymakers, and researchers for revising appropriateness criteria and planning de-implementation. Efforts should be made to reduce the extension and variation of inappropriate imaging which generates huge opportunity costs and is potentially harmful to patients.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

CT:

Computed tomography

CTA:

Computed tomography angiography

DEXA:

Dual-energy X-ray absorptiometry

EVAR:

Endovascular aneurysm repair

MRI:

Magnetic resonance imaging

PET:

Positron emission tomography

US:

Ultrasound

XR:

X-ray

References

  1. Expert Panel on effective ways of investing in Health (EXPH). Defining value in “value-based healthcare. 2019.

  2. Socha K, Couffinhal A, Forde I, Nader C, Cecchini M, Lee S, et al. Tackling wasteful spending on health. OECD 2017. 2017.

  3. Brady A, Brink J, Slavotinek J. Radiology and value-based health care. JAMA. 2020;324(13):1286–7. https://doi.org/10.1001/jama.2020.14930.

    Article  PubMed  Google Scholar 

  4. Brenner DJ, Doll R, Goodhead DT, Hall EJ, Land CE, Little JB, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci. 2003;100(24):13761. https://doi.org/10.1073/pnas.2235592100.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. Andreucci M, Solomon R, Tasanarong A. Side effects of radiographic contrast media: pathogenesis, risk factors, and prevention. Biomed Res Int. 2014;2014: 741018. https://doi.org/10.1155/2014/741018.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA, et al. Addressing overutilization in medical imaging. Radiology. 2010;257(1):240–5. https://doi.org/10.1148/radiol.10100063.

    Article  PubMed  Google Scholar 

  7. Sheng AY, Castro A, Lewiss RE. Awareness, utilization, and education of the ACR appropriateness criteria: a review and future directions. J Am Coll Radiol. 2016;13(2):131–6. https://doi.org/10.1016/j.jacr.2015.08.026.

    Article  PubMed  Google Scholar 

  8. Ingraham B, Miller K, Iaia A, Sneider MB, Naqvi S, Evans K, et al. Reductions in high-end imaging utilization with radiology review and consultation. J Am Coll Radiol. 2016;13(9):1079–82. https://doi.org/10.1016/j.jacr.2016.04.016.

    Article  PubMed  Google Scholar 

  9. Choosing Wisely [Internet]. 2021. https://www.choosingwisely.org/getting-started/lists/.

  10. Improving health and social care through evidence-based guidance [Internet]. 2021. https://www.nice.org.uk/.

  11. Ryan JW, Hollywood A, Stirling A, Glynn M, MacMahon PJ, Bolster F. Evidenced-based radiology? A single-institution review of imaging referral appropriateness including monetary and dose estimates for inappropriate scans. Ir J Med Sci. 2019;188(4):1385–9. https://doi.org/10.1007/s11845-019-02005-8.

    Article  PubMed  Google Scholar 

  12. Chandra K, Atkinson PR, Chatur H, Fraser J, Adams CL. To choose or not to choose: evaluating the effect of a choosing wisely knowledge translation initiative for imaging in low back pain by emergency physicians. Cureus. 2019;11(2): e4002. https://doi.org/10.7759/cureus.4002.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Barth JH, Misra S, Aakre KM, Langlois MR, Watine J, Twomey PJ, et al. Why are clinical practice guidelines not followed? Clin Chem Lab Med. 2016;54(7):1133–9. https://doi.org/10.1515/cclm-2015-0871.

    CAS  Article  PubMed  Google Scholar 

  14. DeAngelis J, Lou V, Li T, Tran H, Bremjit P, McCann M, et al. Head CT for minor head injury presenting to the emergency department in the era of choosing wisely. West J Emerg Med. 2017;18(5):821–9. https://doi.org/10.5811/westjem.2017.6.33685.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Anderson TS, Leonard S, Zhang AJ, Madden E, Mowery D, Chapman WW, et al. Trends in low-value carotid imaging in the veterans health administration from 2007 to 2016. JAMA Netw Open. 2020;3(9):e2015250-e.

    Article  Google Scholar 

  16. Berezin L, Thompson C, Rojas-Luengas V, Borgundvaag B, McLeod SL. Lumbosacral spinal imaging for patients presenting to the emergency department with nontraumatic low back pain. J Emerg Med. 2020;58(2):269–74. https://doi.org/10.1016/j.jemermed.2019.12.017.

    Article  PubMed  Google Scholar 

  17. Müskens JLJM, Kool RB, van Dulmen SA, Westert GP. Overuse of diagnostic testing in healthcare: a systematic review. BMJ Qual Saf. 2021. https://doi.org/10.1136/bmjqs-2020-012576.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. https://doi.org/10.7326/m18-0850.

    Article  PubMed  Google Scholar 

  19. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doi.org/10.1186/s13643-016-0384-4.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Cellina M, Panzeri M, Floridi C, Martinenghi CMA, Clesceri G, Oliva G. Overuse of computed tomography for minor head injury in young patients: an analysis of promoting factors. Radiol Med. 2018;123(7):507–14. https://doi.org/10.1007/s11547-018-0871-x.

    Article  PubMed  Google Scholar 

  21. Parma C, Carney D, Grim R, Bell T, Shoff K, Ahuja V. Unnecessary head computed tomography scans: a level 1 trauma teaching experience. Am Surg. 2014;80(7):664–8. https://doi.org/10.1177/000313481408000720.

    Article  PubMed  Google Scholar 

  22. Shobeirian F, Ghomi Z, Soleimani R, Mirshahi R, Sanei Taheri M. Overuse of brain CT scan for evaluating mild head trauma in adults. Emerg Radiol. 2020. https://doi.org/10.1007/s10140-020-01846-6.

    Article  PubMed  Google Scholar 

  23. Ferorelli D, Donno F, De Giorgio G, Mele F, Favia M, Riefoli F, et al. Head CT scan in emergency room: is it still abused? Quantification and causes analysis of overprescription in an Italian Emergency Department. Radiol Med. 2020;125(6):595–9. https://doi.org/10.1007/s11547-020-01143-9.

    Article  PubMed  Google Scholar 

  24. Yildizhan S, Boyaci MG, Ozdinc S. How necessary is the computerized brain tomography in minor head trauma? Ulus Travma ve Acil Cerrahi Derg. 2019;25(4):378–82.

    Google Scholar 

  25. Yun BJ, Borczuk P, Zachrison KS, Goldstein JN, Berlyand Y, Raja AS. Utilization of head CT during injury visits to United States emergency departments: 2012–2015. Am J Emerg Med. 2018;36(8):1463–6. https://doi.org/10.1016/j.ajem.2018.05.018.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Zargar Balaye Jame S, Majdzadeh R, Akbari Sari A, Rashidian A, Arab M, Rahmani H. Indications and overuse of computed tomography in minor head trauma. Iran Red Crescent Med J. 2014;16(5):3067. https://doi.org/10.5812/ircmj.13067.

    Article  Google Scholar 

  27. Zuzek P, Rigler I, Podnar S. Validation of clinical criteria for referral to head imaging in the neurologic emergency setting. Neurol Sci. 2019;40(12):2541–8. https://doi.org/10.1007/s10072-019-04009-9.

    Article  PubMed  Google Scholar 

  28. Theisen-Toupal J, Breu AC, Mattison ML, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium. J Hosp Med. 2014;9(8):497–501. https://doi.org/10.1002/jhm.2198.

    Article  PubMed  Google Scholar 

  29. Vijayakrishnan R, Ramasubramanian A, Dhand S. Utility of head CT scan for acute inpatient delirium. Hosp Top. 2015;93(1):9–12. https://doi.org/10.1080/00185868.2015.1012928.

    Article  PubMed  Google Scholar 

  30. Ali AHA, Al-Ghamdi S, Karrar MH, Alajmi SA, Almutairi OS, Aldalbahi AM, et al. Is there a misuse of computed tomography in the diagnostic workup of headache? A retrospective record-based study in secondary health-care facility in Saudi Arabia. J Family Med Prim Care. 2018;7(2):357–61. https://doi.org/10.4103/jfmpc.jfmpc_338_17.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wang R, Liu R, Dong Z, Su H, Ao R, Liu Y, et al. Unnecessary neuroimaging for patients with primary headaches. Headache. 2018;59(1):63–8. https://doi.org/10.1111/head.13397.

    CAS  Article  PubMed  Google Scholar 

  32. You JJ, Gladstone J, Symons S, Rotstein D, Laupacis A, Bell CM. Patterns of care and outcomes after computed tomography scans for headache. Am J Med. 2011;124(1):58-63.e1. https://doi.org/10.1016/j.amjmed.2010.08.010.

    Article  PubMed  Google Scholar 

  33. Campiglio L, Bianchi F, Cattalini C, Belvedere D, Rosci CE, Casellato CL, et al. Mild brain injury and anticoagulants: less is enough. Neurol Clin Pract. 2017;7(4):296–305. https://doi.org/10.1212/CPJ.0000000000000375.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kumar S, Modi R, Bhandari BM, Sass DA, Rothstein KD. A head CT is unnecessary in the initial evaluation of a cirrhotic patient with recurrent hepatic encephalopathy. Ann Hepatol. 2018;17(5):810–4. https://doi.org/10.5604/01.3001.0012.3141.

    Article  PubMed  Google Scholar 

  35. Nagra I, Wee B, Short J, Banerjee AK. The role of cranial CT in the investigation of meningitis. JRSM Short Rep. 2011;2(3):20. https://doi.org/10.1258/shorts.2011.010113.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Maniar H, McPhillips K, Torres D, Wild J, Suk M, Horwitz DS. Clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures. Injury. 2015;46(11):2185–9. https://doi.org/10.1016/j.injury.2015.06.036.

    Article  PubMed  Google Scholar 

  37. Danielson K, Hall T, Endres T, Jones C, Sietsema D. Clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures: a follow-up study at a community hospital. Geriatr Orthop Surg Rehabil. 2019;10:2151459319861562. https://doi.org/10.1177/2151459319861562.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Owlia M, Yu L, Deible C, Hughes MA, Jovin F, Bump GM. Head CT scan overuse in frequently admitted medical patients. Am J Med. 2014;127(5):406–10. https://doi.org/10.1016/j.amjmed.2014.01.023.

    Article  PubMed  Google Scholar 

  39. Ramey P, Osborn M, Kirshner H, Abou-Khalil B. Misdiagnosis of lamotrigine toxicity as posterior circulation transient ischemic attack or stroke. Epilepsy Behav. 2020;111:107284.

    Article  PubMed  Google Scholar 

  40. Connon FF, Namdarian B, Ee JL, Drummond KJ, Miller JA. Do routinely repeated computed tomography scans in traumatic brain injury influence management? A prospective observational study in a level 1 trauma center. Ann Surg. 2011;254(6):1028–31. https://doi.org/10.1097/SLA.0b013e318219727f.

    Article  PubMed  Google Scholar 

  41. Befeler AR, Gordon W, Khan N, Fernandez J, Muhlbauer MS, Sorenson JM. Results of delayed follow-up imaging in traumatic brain injury. J Neurosurg. 2016;124(3):703–9. https://doi.org/10.3171/2015.4.JNS141257.

    Article  PubMed  Google Scholar 

  42. Almenawer SA, Bogza I, Yarascavitch B, Sne N, Farrokhyar F, Murty N, et al. The value of scheduled repeat cranial computed tomography after mild head injury: single-center series and meta-analysis. Neurosurgery. 2013;72(1):56–62. https://doi.org/10.1227/NEU.0b013e318276f899 (discussion 3-4).

    Article  PubMed  Google Scholar 

  43. AbdelFattah KR, Eastman AL, Aldy KN, Wolf SE, Minei JP, Scott WW, et al. A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15. J Trauma Acute Care Surg. 2012;73(3):685–8. https://doi.org/10.1097/TA.0b013e318265ccd9.

    Article  PubMed  Google Scholar 

  44. Rosen CB, Luy DD, Deane MR, Scalea TM, Stein DM. Routine repeat head CT may not be necessary for patients with mild TBI. Trauma Surg Acute Care Open. 2018;3(1):e000129.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Stippler M, Smith C, McLean AR, Carlson A, Morley S, Murray-Krezan C, et al. Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature. Emerg Med J. 2012;29(7):528–32. https://doi.org/10.1136/emermed-2011-200162.

    Article  PubMed  Google Scholar 

  46. Kaen A, Jimenez-Roldan L, Arrese I, Amosa Delgado M, Lopez PG, Alday R, et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma. 2010;68(4):895–8. https://doi.org/10.1097/TA.0b013e3181b28a76.

    CAS  Article  PubMed  Google Scholar 

  47. McCammack KC, Sadler C, Guo Y, Ramaswamy RS, Farid N. Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury. West J Emerg Med. 2015;16(1):43–9. https://doi.org/10.5811/westjem.2014.10.19488.

    Article  PubMed  Google Scholar 

  48. Reljic T, Mahony H, Djulbegovic B, Etchason J, Paxton H, Flores M, et al. Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis. J Neurotrauma. 2014;31(1):78–98. https://doi.org/10.1089/neu.2013.2873.

    Article  PubMed  Google Scholar 

  49. Sifri ZC, Nyak N, Homnick AT, Mohr AA, Yonclas P, Livingston DH. Utility of repeat head computed tomography in patients with an abnormal neurologic examination after minimal head injury. J Trauma. 2011;71(6):1605–10. https://doi.org/10.1097/TA.0b013e31822b3728.

    Article  PubMed  Google Scholar 

  50. Washington CW, Grubb RL. Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? J Neurosurg. 2012;116(3):549–57.

    Article  PubMed  Google Scholar 

  51. Peck KA, Sise CB, Shackford SR, Sise MJ, Calvo RY, Sack DI, et al. Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? J Trauma. 2011;71(6):1600–4. https://doi.org/10.1097/TA.0b013e31823b9ce1.

    CAS  Article  PubMed  Google Scholar 

  52. Uccella L, Zoia C, Perlasca F, Bongetta D, Codecà R, Gaetani P. Mild traumatic brain injury in patients on long-term anticoagulation therapy: do they really need repeated head CT scan? World Neurosurg. 2016;93:100–3. https://doi.org/10.1016/j.wneu.2016.05.061.

    Article  PubMed  Google Scholar 

  53. Flaherty BF, Moore HE, Riva-Cambrin J, Bratton SL. Repeat head CT for expectant management of traumatic epidural hematoma. Pediatrics. 2018;142(3):e20180385. https://doi.org/10.1542/peds.2018-0385.

    Article  PubMed  Google Scholar 

  54. Behmanesh B, Keil F, Dubinski D, Won SY, Quick-Weller J, Seifert V, et al. The value of computed tomography imaging of the head after ventriculoperitoneal shunt surgery in adults. World Neurosurg. 2019;121:e159–64. https://doi.org/10.1016/j.wneu.2018.09.063.

    Article  PubMed  Google Scholar 

  55. Ng HY, Ng WH, King NK. Value of routine early post-operative computed tomography in determining short-term functional outcome after drainage of chronic subdural hematoma: an evaluation of residual volume. Surg Neurol Int. 2014;5(1):136. https://doi.org/10.4103/2152-7806.141299.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Nadimi S, Caballero N, Carpenter P, Sowa L, Cunningham R, Welch KC. Immediate postoperative imaging after uncomplicated endoscopic approach to the anterior skull base: is it necessary? Int Forum Allergy Rhinol. 2014;4(12):1024–9.

    Article  PubMed  Google Scholar 

  57. Abboud H, Mente K, Seay M, Kim J, Ali A, Bermel R, et al. Triaging patients with multiple sclerosis in the emergency department: room for improvement. Int J MS Care. 2017;19(6):290–6. https://doi.org/10.7224/1537-2073.2016-069.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Cho H, Lee HY, Kim J, Kim HK, Choi JY, Um SW, et al. Pure ground glass nodular adenocarcinomas: are preoperative positron emission tomography/computed tomography and brain magnetic resonance imaging useful or necessary? J Thorac Cardiovasc Surg. 2015;150(3):514–20. https://doi.org/10.1016/j.jtcvs.2015.06.024.

    Article  PubMed  Google Scholar 

  59. Eroukhmanoff J, Tejedor I, Potorac I, Cuny T, Bonneville JF, Dufour H, et al. MRI follow-up is unnecessary in patients with macroprolactinomas and long-term normal prolactin levels on dopamine agonist treatment. Eur J Endocrinol. 2017;176(3):323–8. https://doi.org/10.1530/EJE-16-0897.

    CAS  Article  PubMed  Google Scholar 

  60. Viau JA, Chaudry H, Hannigan A, Boutet M, Mukarram M, Thiruganasambandamoorthy V. The yield of computed tomography of the head among patients presenting with syncope: a systematic review. Acad Emerg Med. 2019;26(5):479–90. https://doi.org/10.1111/acem.13568.

    Article  PubMed  Google Scholar 

  61. Johnson PC, Ammar H, Zohdy W, Fouda R, Govindu R. Yield of diagnostic tests and its impact on cost in adult patients with syncope presenting to a community hospital. South Med J. 2014;107(11):707–14. https://doi.org/10.14423/SMJ.0000000000000184.

    Article  PubMed  Google Scholar 

  62. Peres MFP, Swerts DB, de Oliveira AB, Silva-Neto RP. Migraine patients’ journey until a tertiary headache center: an observational study. J Headache Pain. 2019;20(1):88. https://doi.org/10.1186/s10194-019-1039-3.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  63. Shuaib W, Johnson JO, Pande V, Salastekar N, Kang J, He Q, et al. Ventriculoperitoneal shunt malfunction: cumulative effect of cost, radiation, and turnaround time on the patient and the health care system. AJR Am J Roentgenol. 2014;202(1):13–7. https://doi.org/10.2214/AJR.13.11176.

    Article  PubMed  Google Scholar 

  64. Raza SA, Javalkar V, Dehkharghani S, Kudrimoti A, Saindane A, Mullins M, et al. Utility of repeat cerebrovascular imaging among hospitalized stroke patients. J Stroke Cerebrovasc Dis. 2017;26(7):1588–93. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.02.029.

    Article  PubMed  Google Scholar 

  65. Al Shakarchi J, Lowry D, Nath J, Khawaja AZ, Inston N, Tiwari A. Duplex ultrasound surveillance after carotid artery endarterectomy. J Vasc Surg. 2016;63(6):1647–50. https://doi.org/10.1016/j.jvs.2016.01.054.

    Article  PubMed  Google Scholar 

  66. Scott JW, Schwartz AL, Gates JD, Gerhard-Herman M, Havens JM. Choosing wisely for syncope: low-value carotid ultrasound use. J Am Heart Assoc. 2014;3(4):e001063. https://doi.org/10.1161/JAHA.114.001063.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Rose MK, Rosal LM, Gonzalez RP, Rostas JW, Baker JA, Simmons JD, et al. Clinical clearance of the cervical spine in patients with distracting injuries: it is time to dispel the myth. J Trauma Acute Care Surg. 2012;73(2):498–502. https://doi.org/10.1097/TA.0b013e3182587634.

    Article  PubMed  Google Scholar 

  68. Uriell ML, Allen JW, Lovasik BP, Benayoun MD, Spandorfer RM, Holder CA. Yield of computed tomography of the cervical spine in cases of simple assault. Injury. 2017;48(1):133–6. https://doi.org/10.1016/j.injury.2016.10.031.

    Article  PubMed  Google Scholar 

  69. Benayoun MD, Allen JW, Lovasik BP, Uriell ML, Spandorfer RM, Holder CA. Utility of computed tomographic imaging of the cervical spine in trauma evaluation of ground-level fall. J Trauma Acute Care Surg. 2016;81(2):339–44. https://doi.org/10.1097/TA.0000000000001073.

    Article  PubMed  Google Scholar 

  70. Novick D, Wallace R, DiGiacomo JC, Kumar A, Lev S, Angus LDG. The cervical spine can be cleared without MRI after blunt trauma: a retrospective review of a single level 1 trauma center experience over 8 years. Am J Surg. 2018;216(3):427–30. https://doi.org/10.1016/j.amjsurg.2018.03.003.

    Article  PubMed  Google Scholar 

  71. Subramanian M, Hranjec T, Liu L, Hodgman EI, Minshall CT, Minei JP. A case for less workup in near hanging. J Trauma Acute Care Surg. 2016;81(5):925–30. https://doi.org/10.1097/TA.0000000000001231.

    Article  PubMed  Google Scholar 

  72. Ghaffarpasand F, Paydar S, Foroughi M, Saberi A, Abbasi H, Karimi AA, et al. Role of cervical spine radiography in the initial evaluation of stable high-energy blunt trauma patients. J Orthop Sci. 2011;16(5):498–502. https://doi.org/10.1007/s00776-011-0132-5.

    Article  PubMed  Google Scholar 

  73. Bartels RHMA, Beems T, Schutte PJ, Verbeek ALM. The rationale of postoperative radiographs after cervical anterior discectomy with stand-alone cage for radicular pain. J Neurosurg Spine. 2010;12(3):275–9. https://doi.org/10.3171/2009.9.SPINE09263.

    Article  PubMed  Google Scholar 

  74. Grimm BD, Leas DP, Glaser JA. The utility of routine postoperative radiographs after cervical spine fusion. Spine J. 2013;13(7):764–9. https://doi.org/10.1016/j.spinee.2013.01.018.

    Article  PubMed  Google Scholar 

  75. Shau DN, Bible JE, Samade R, Gadomski SP, Mushtaq B, Wallace A, et al. Utility of postoperative radiographs for cervical spine fusion a comprehensive evaluation of operative technique, surgical indication, and duration since surgery. Spine. 2012;37(24):1994–2000. https://doi.org/10.1097/BRS.0b013e31825c0130.

    Article  PubMed  Google Scholar 

  76. Martin SC, Dabbous BO, Ridgeon EE, Magdum SA, Cadoux-Hudson TA, Pereira EA. Routine radiographs one day after anterior cervical discectomy and fusion are neither necessary nor cost-effective. Br J Neurosurg. 2017;31(1):50–3. https://doi.org/10.1080/02688697.2016.1233320.

    Article  PubMed  Google Scholar 

  77. Tran B, Saxe JM, Ekeh AP. Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan? J Surg Res. 2013;184(1):411–3. https://doi.org/10.1016/j.jss.2013.05.100.

    Article  PubMed  Google Scholar 

  78. Ali IS, Khan M, Khan MA. Routine preoperative chest x-ray and its impact on decision making in patients undergoing elective surgical procedures. J Ayub Med Coll Abbottabad. 2013;25(1–2):23–5.

    PubMed  Google Scholar 

  79. Kröner A, Beenen L, du Raan M, Meijer P, Spronk PE, Stoker J, et al. The clinical value of routinely obtained postoperative chest radiographs in post-anaesthesia care unit patients seems poor-a prospective observational study. Ann Transl Med. 2018;6(18):360. https://doi.org/10.21037/atm.2018.08.33.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Loggers SAI, Giannakopoulos GF, Vandewalle E, Erwteman M, Berger F, Zuidema WP. Preoperative chest radiographs in hip fracture patients: is there any additional value? Eur J Orthop Surg Traumatol. 2017;27(7):953–9. https://doi.org/10.1007/s00590-017-1971-3.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Thanh NX, Rashiq S, Jonsson E. Routine preoperative electrocardiogram and chest x-ray prior to elective surgery in Alberta, Canada. Can J Anaesth. 2010;57(2):127–33. https://doi.org/10.1007/s12630-009-9233-4.

    Article  PubMed  Google Scholar 

  82. De La Pena H, Sharma A, Glicksman C, Joseph J, Subesinghe M, Traill Z, et al. No longer any role for routine follow-up chest x-rays in men with stage I germ cell cancer. Eur J Cancer. 2017;84:354–9. https://doi.org/10.1016/j.ejca.2017.07.005.

    Article  Google Scholar 

  83. Hovgaard TB, Nymark T, Skov O, Petersen MM. Follow-up after initial surgical treatment of soft tissue sarcomas in the extremities and trunk wall. Acta Oncol. 2017;56(7):1004–12. https://doi.org/10.1080/0284186X.2017.1299937.

    Article  PubMed  Google Scholar 

  84. Hoogendam JP, Zweemer RP, Verkooijen HM, de Jong PA, van den Bosch MA, Verheijen RH, et al. No value for routine chest radiography in the work-up of early stage cervical cancer patients. PLoS ONE. 2015;10(7): e0131899. https://doi.org/10.1371/journal.pone.0131899.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  85. Louie RJ, Tonneson JE, Gowarty M, Goodney PP, Barth RJ, Rosenkranz KM. Complete blood counts, liver function tests, and chest x-rays as routine screening in early-stage breast cancer: value added or just cost? Breast Cancer Res Treat. 2015;154(1):99–103. https://doi.org/10.1007/s10549-015-3593-y.

    Article  PubMed  Google Scholar 

  86. Izamin I, Rizal AM. Chest x-ray as an essential part of routine medical examination: is it necessary? Med J Malaysia. 2012;67(6):606–9.

    CAS  PubMed  Google Scholar 

  87. Shimoni Z, Rosenberg M, Amit L, Froom P. Chest radiography should be requested only on admission based on clinical grounds. South Med J. 2020;113(1):20–2. https://doi.org/10.14423/Smj.0000000000001051.

    Article  PubMed  Google Scholar 

  88. Verma V, Vasudevan V, Jinnur P, Nallagatla S, Majumdar A, Arjomand F, et al. The utility of routine admission chest X-ray films on patient care. Eur J Intern Med. 2011;22(3):286–8. https://doi.org/10.1016/j.ejim.2010.12.007.

    Article  PubMed  Google Scholar 

  89. Alazzawi S, De Rover WS, Morris-Stiff G, Lewis MH. Erect chest radiography in the setting of the acute abdomen: essential tool or an unnecessary waste of resources? Ann R Coll Surg Engl. 2010;92(8):697–9. https://doi.org/10.1308/003588410X12699663904998.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  90. Paydar S, Johari HG, Ghaffarpasand F, Shahidian D, Dehbozorgi A, Ziaeian B, et al. The role of routine chest radiography in initial evaluation of stable blunt trauma patients. Am J Emerg Med. 2012;30(1):1–4. https://doi.org/10.1016/j.ajem.2010.08.010.

    Article  PubMed  Google Scholar 

  91. Zieleskiewicz L, Fresco R, Duclos G, Antonini F, Mathieu C, Medam S, et al. Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: impact on the management of 756 patients. Injury. 2018;49(10):1774–80. https://doi.org/10.1016/j.injury.2018.07.002.

    Article  PubMed  Google Scholar 

  92. Greig CJ, Keiser AM, Cleary MA, Stitelman DH, Christison-Lagay ER, Ozgediz DE, et al. Routine postnatal chest x-ray and intensive care admission are unnecessary for a majority of infants with congenital lung malformations. J Pediatr Surg. 2019;54(4):670–4. https://doi.org/10.1016/j.jpedsurg.2018.10.063.

    Article  PubMed  Google Scholar 

  93. Lemmers M, Saltzherr TP, Beenen LF, Ponsen KJ, Goslings JC. Are routine repeat chest x-rays before leaving the trauma room useful? Emerg Med J. 2010;27(7):522–5. https://doi.org/10.1136/emj.2009.078519.

    CAS  Article  PubMed  Google Scholar 

  94. Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Routinely obtained chest X-rays after elective video-assisted thoracoscopic surgery can be omitted in most patients; a retrospective, observational study. Gen Thorac Cardiovasc Surg. 2015;63(8):465–71. https://doi.org/10.1007/s11748-015-0560-9.

    Article  PubMed  Google Scholar 

  95. Leschber G, May CJ, Simbrey-Chryselius N. Do thoracic surgery patients always need a postoperative chest X-ray? Zentralbl Chir. 2014;139(Suppl 1):S43–9. https://doi.org/10.1055/s-0034-1383034.

    Article  PubMed  Google Scholar 

  96. Chui J, Saeed R, Jakobowski L, Wang W, Eldeyasty B, Zhu F, et al. Is routine chest X-ray after ultrasound-guided central venous catheter insertion choosing wisely?: A population-based retrospective study of 6875 patients. Chest. 2018;154(1):148–56. https://doi.org/10.1016/j.chest.2018.02.017.

    Article  PubMed  Google Scholar 

  97. Cunningham JP, Knott EM, Gasior AC, Juang D, Snyder CL, St. Peter SD, et al. Is routine chest radiograph necessary after chest tube removal? J Pediatr Surg. 2014;49(10):1493–5. https://doi.org/10.1016/j.jpedsurg.2014.01.004.

    Article  PubMed  Google Scholar 

  98. Dalton BGA, Gonzalez KW, Keirsy MC, Rivard DC, St. Peter SD. Chest radiograph after fluoroscopic guided line placement: no longer necessary. J Pediatr Surg. 2016;51(9):1490–1. https://doi.org/10.1016/j.jpedsurg.2016.02.003.

    Article  PubMed  Google Scholar 

  99. Eisenberg RL, Khabbaz KR. Are chest radiographs routinely indicated after chest tube removal following cardiac surgery? AJR Am J Roentgenol. 2011;197(1):122–4. https://doi.org/10.2214/AJR.10.5856.

    Article  PubMed  Google Scholar 

  100. Farzan R, Shojaee R, Haghdoost A, Mobayen M. Comparison of chest X-ray and clinical findings in trauma patients after chest tube removal. J Clin Diagn Res. 2018;12(7):Pc19–21. https://doi.org/10.7860/Jcdr/2018/31989.11833.

    Article  Google Scholar 

  101. Goodman MD, Huber NL, Johannigman JA, Pritts TA. Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients. Am J Surg. 2010;199(2):199–203. https://doi.org/10.1016/j.amjsurg.2009.03.011.

    Article  PubMed  Google Scholar 

  102. Hourmozdi JJ, Markin A, Johnson B, Fleming PR, Miller JB. Routine chest radiography is not necessary after ultrasound-guided right internal jugular vein catheterization. Crit Care Med. 2016;44(9):e804–8. https://doi.org/10.1097/CCM.0000000000001737.

    Article  PubMed  Google Scholar 

  103. Izbicki G, Romem A, Arish N, Cahan C, Azulai H, Chen-Shuali C, et al. Avoiding routine chest radiography after transbronchial biopsy is safe. Respiration. 2016;92(3):176–81. https://doi.org/10.1159/000448688.

    Article  PubMed  Google Scholar 

  104. Johnson B, Rylander M, Beres AL. Do X-rays after chest tube removal change patient management? J Pediatr Surg. 2017;52(5):813–5. https://doi.org/10.1016/j.jpedsurg.2017.01.047.

    Article  PubMed  Google Scholar 

  105. Miccini M, Cassini D, Gregori M, Gazzanelli S, Cassibba S, Biacchi D. Ultrasound-guided placement of central venous port systems via the right internal jugular vein: are chest X-ray and/or fluoroscopy needed to confirm the correct placement of the device? World J Surg. 2016;40(10):2353–8. https://doi.org/10.1007/s00268-016-3574-2.

    Article  PubMed  Google Scholar 

  106. Porter ED, Fay KA, Hasson RM, Millington TM, Finley DJ, Phillips JD. Routine chest X-rays after thoracic surgery are unnecessary. J Surg Res. 2020;250:188–92. https://doi.org/10.1016/j.jss.2019.12.030.

    Article  PubMed  Google Scholar 

  107. Woodland DC, Randall Cooper C, Farzan Rashid M, Rosario VL, Weyker PD, Weintraub J, et al. Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room. J Crit Care. 2018;46:13–6.

    Article  PubMed  Google Scholar 

  108. Cerfolio RJ, Bryant AS. Daily chest roentgenograms are unnecessary in nonhypoxic patients who have undergone pulmonary resection by thoracotomy. Ann Thorac Surg. 2011;92(2):440–3. https://doi.org/10.1016/j.athoracsur.2011.04.002.

    Article  PubMed  Google Scholar 

  109. Eisenmann S, Winantea J, Karpf-Wissel R, Funke F, Stenzel E, Taube C, et al. Thoracic ultrasound for immediate exclusion of pneumothorax after interventional bronchoscopy. J Clin Med. 2020;9(5):1486. https://doi.org/10.3390/jcm9051486.

    Article  PubMed Central  Google Scholar 

  110. Farach SM, Danielson PD, Chandler NM. The role of chest radiography following pectus bar removal. Pediatr Surg Int. 2016;32(7):705–8. https://doi.org/10.1007/s00383-016-3905-2.

    Article  PubMed  Google Scholar 

  111. Knudsen MR, Nyboe C, Hjortdal VE, Pilegaard HK. Routine postoperative chest X-ray is unnecessary following the Nuss procedure for pectus excavatum. Interact Cardiovasc Thorac Surg. 2013;16(6):830–3. https://doi.org/10.1093/icvts/ivt052.

    Article  PubMed  PubMed Central  Google Scholar 

  112. Sola R, Yu YR, Friske TC, Jamal AR, Rosenfeld EH, Mazziotti MV, et al. Repetitive imaging following minimally invasive repair of pectus excavatum is unnecessary. Eur J Pediatr Surg. 2019;29(5):408–11. https://doi.org/10.1055/s-0038-1660868.

    Article  PubMed  Google Scholar 

  113. Velicković JV, Hajdarević SA, Palibrk IG, Janić NR, Djukanović M, Miljković B, et al. Routine chest radiographs in the surgical intensive care unit: can we change clinical habits with no proven benefit? Acta Chir Iugosl. 2013;60(3):39–44.

    Article  PubMed  Google Scholar 

  114. Pathak T, Parmar MS. (F)utility of computed tomography of the chest in the presence of pleural effusion. Pleura Peritoneum. 2017;2(4):181–6. https://doi.org/10.1515/pp-2017-0019.

    Article  PubMed  PubMed Central  Google Scholar 

  115. Fatihoglu E, Aydin S, Gokharman FD, Ece B, Kosar PN. X-ray use in chest imaging in emergency department on the basis of cost and effectiveness. Acad Radiol. 2016;23(10):1239–45. https://doi.org/10.1016/j.acra.2016.05.008.

    Article  PubMed  Google Scholar 

  116. Kim H, Han W, Moon H-G, Min J, Ahn S-K, Kim T-Y, et al. The value of preoperative staging chest computed tomography to detect asymptomatic lung and liver metastasis in patients with primary breast carcinoma. Breast Cancer Res Treat. 2011;126(3):637–41. https://doi.org/10.1007/s10549-011-1368-7.

    CAS  Article  PubMed  Google Scholar 

  117. Zhou Y, Zheng Y, Yang Q, Hu L, Liao J, Li X. Cohort study of chest CT and clinical changes in 29 patients with coronavirus disease 2019 (COVID-19). Eur Radiol. 2020;30(11):6213–20. https://doi.org/10.1007/s00330-020-07007-0.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  118. Bjurlin MA, O’Grady T, Kim R, Jordan MD, Goble SM, Hollowell CM. Is routine postoperative chest radiography needed after percutaneous nephrolithotomy? Urology. 2012;79(4):791–5. https://doi.org/10.1016/j.urology.2011.08.053.

    Article  PubMed  Google Scholar 

  119. Mikhael A, Patell R, Tabet M, Bena J, Berber E, Nasr C. Chest X-ray prior to thyroidectomy: is it really needed? World J Surg. 2018;42(5):1403–7. https://doi.org/10.1007/s00268-017-4357-0.

    Article  PubMed  Google Scholar 

  120. Cruz J, Ferra M, Kasarabada A, Gasperino J, Zigmund B. Evaluation of the clinical utility of routine daily chest radiography in intensive care unit patients with tracheostomy tubes: a retrospective review. J Intensive Care Med. 2016;31(5):333–7. https://doi.org/10.1177/0885066614538393.

    Article  PubMed  Google Scholar 

  121. Karel YH, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: a meta-analysis. Eur J Intern Med. 2015;26(8):585–95. https://doi.org/10.1016/j.ejim.2015.06.018.

    Article  PubMed  Google Scholar 

  122. Khanduja S, Loomba V, Salama-Hannah J, Upadhyay A, Khanduja N, Chauhan G. Retrospective review of magnetic resonance imaging of the lumbosacral spine: are we overinvestigating? Neurospine. 2018;15(4):383–7. https://doi.org/10.14245/ns.1836110.055.

    Article  PubMed  PubMed Central  Google Scholar 

  123. Salari H, Ostovar R, Esfandiari A, Keshtkaran A, Akbari Sari A, Yousefi Manesh H, et al. Evidence for policy making: clinical appropriateness study of lumbar spine MRI prescriptions using RAND appropriateness method. Int J Health Policy Manag. 2013;1(1):17–21. https://doi.org/10.15171/ijhpm.2013.04.

    Article  PubMed  PubMed Central  Google Scholar 

  124. Tan AL, Zhou J, Kuo YF, Goodwin JS. Variation among primary care physicians in the use of imaging for older patients with acute low back pain. J Gen Intern Med. 2016;31(2):156–63. https://doi.org/10.1007/s11606-015-3475-3.

    Article  PubMed  Google Scholar 

  125. Wnuk NM, Alkasab TK, Rosenthal DI. Magnetic resonance imaging of the lumbar spine: determining clinical impact and potential harm from overuse. Spine J. 2018;18(9):1653–8. https://doi.org/10.1016/j.spinee.2018.04.005.

    Article  PubMed  Google Scholar 

  126. Yu LD, Wang XW, Lin XJ, Wang Y. The use of lumbar spine magnetic resonance imaging in eastern China: appropriateness and related factors. PLoS ONE. 2016;11(1):e0146369. https://doi.org/10.1371/journal.pone.0146369.

    Article  PubMed  PubMed Central  Google Scholar 

  127. Zargar BJS, Sari AA, Majdzadeh R, Rashidian A, Arab M, Rahmani H. The extent of inappropriate use of magnetic resonance imaging in low back pain and its contributory factors. Int J Prev Med. 2014;5(8):1029–36.

    Google Scholar 

  128. Jahanmehr N, Bigdeli AS, Salari H, Mokarami H, KhodaKarim S, Damiri S. Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain. Int J Health Plann Manag. 2019;34(4):e1437–47. https://doi.org/10.1002/hpm.2806.

    Article  Google Scholar 

  129. Logan GS, Pike A, Copsey B, Parfrey P, Etchegary H, Hall A. What do we really know about the appropriateness of radiation emitting imaging for low back pain in primary and emergency care? A systematic review and meta-analysis of medical record reviews. PLoS ONE. 2019;14(12):e0225414. https://doi.org/10.1371/journal.pone.0225414.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  130. Schlemmer E, Mitchiner JC, Brown M, Wasilevich E. Imaging during low back pain ED visits: a claims-based descriptive analysis. Am J Emerg Med. 2015;33(3):414–8. https://doi.org/10.1016/j.ajem.2014.12.060.

  131. Leichtle UG, Wunschel M, Socci M, Kurze C, Niemeyer T, Leichtle CI. Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic. J Back Musculoskelet Rehabil. 2015;28(1):43–8. https://doi.org/10.3233/BMR-140488.

    Article  PubMed  Google Scholar 

  132. Molinari RWMD, Hunter JGMD, McAssey RWBS. In-hospital postoperative radiographs for instrumented single-level degenerative spinal fusions: utility after intraoperative fluoroscopy. Spine J. 2012;12(7):559–67. https://doi.org/10.1016/j.spinee.2012.06.005.

    Article  PubMed  Google Scholar 

  133. Simpson AK, Osler P, Wood KB. Utility of postoperative radiographs after anterior lumbar interbody fusion with or without posterior instrumentation. Spine. 2013;38(23):2038–42. https://doi.org/10.1097/BRS.0b013e3182a81f67.

    Article  PubMed  Google Scholar 

  134. Yamashita T, Steinmetz MP, Lieberman IH, Modic MT, Mroz TE. The utility of repeated postoperative radiographs after lumbar instrumented fusion for degenerative lumbar spine. Spine. 2011;36(23):1955–60. https://doi.org/10.1097/BRS.0b013e31820125b5.

    Article  PubMed  Google Scholar 

  135. Natoli RM, Fogel HA, Holt D, Schiff A, Bernstein M, Summers HD, et al. Advanced imaging lacks clinical utility in treating geriatric pelvic ring injuries caused by low-energy trauma. J Orthop Trauma. 2017;31(4):194–9. https://doi.org/10.1097/BOT.0000000000000761.

    Article  PubMed  Google Scholar 

  136. Bolt C, O’Keeffe F, Finnegan P, Dickson K, Smit V, Fitzgerald MC, et al. Straight leg elevation to rule out pelvic injury. Injury. 2018;49(2):279–83. https://doi.org/10.1016/j.injury.2017.10.009.

    Article  PubMed  Google Scholar 

  137. van Trigt J, Schep NWL, Peters RW, Goslings JC, Schepers T, Halm JA. Routine pelvic X-rays in asymptomatic hemodynamically stable blunt trauma patients: a meta-analysis. Injury. 2018;49(11):2024–31. https://doi.org/10.1016/j.injury.2018.09.009.

    Article  PubMed  Google Scholar 

  138. Lechtig A, Barghi A, Wolf BT, Weaver M, Wixted JJ, Rodriguez EK, et al. The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures. Injury. 2019;50(8):1448–51. https://doi.org/10.1016/j.injury.2019.07.005.

    Article  PubMed  Google Scholar 

  139. Westerterp M, Emous M, Vermeulen MC, Eerenberg JP, van Geloven AA. No additional value of routine check X-rays after internal fixation of hip fractures. Eur J Trauma Emerg Surg. 2013;39(2):163–5. https://doi.org/10.1007/s00068-012-0244-4.

    CAS  Article  PubMed  Google Scholar 

  140. Issa K, Jauregui JJ, McElroy M, Banerjee S, Kapadia BH, Mont MA. Unnecessary magnetic resonance imaging of hips: an economic burden to patients and the healthcare system. J Arthroplasty. 2014;29(10):1911–4. https://doi.org/10.1016/j.arth.2014.05.022.

    Article  PubMed  Google Scholar 

  141. Adelani MA, Mall NA, Brophy RH, Halstead ME, Smith MV, Wright RW. The use of MRI in evaluating knee pain in patients aged 40 years and older. J Am Acad Orthop Surg. 2016;24(9):653–9. https://doi.org/10.5435/JAAOS-D-15-00681.

    Article  PubMed  Google Scholar 

  142. Parent ME, Vezina F, Carrier N, Masetto A. Indications for and clinical procedures resulting from magnetic resonance imaging of the knee in older patients: are we choosing wisely? Can Fam Physician. 2018;64(3):e126–32.

    PubMed  PubMed Central  Google Scholar 

  143. Refahi S, Kachooei AR, Farsadpour M, Shahrayeni R, Goudarzian M, Taleghani YM, et al. Is prescription of knee MRI according to standard clinical guideline? Acta Medica Mediterranea. 2016;32:1207–11.

    Google Scholar 

  144. Sheridan GA, Bisseru A, Glynn AA. The utility of MRI scans for a painful knee in the elderly patient. Ir J Med Sci. 2020. https://doi.org/10.1007/s11845-020-02261-z.

    Article  PubMed  Google Scholar 

  145. Smith L, Barratt A, Buchbinder R, Harris IA, Doust J, Bell K. Trends in knee magnetic resonance imaging, arthroscopies and joint replacements in older Australians: still too much low-value care? ANZ J Surg. 2020;90(5):833–9. https://doi.org/10.1111/ans.15712.

    Article  PubMed  Google Scholar 

  146. Solivetti FM, Guerrisi A, Salducca N, Desiderio F, Graceffa D, Capodieci G, et al. Appropriateness of knee MRI prescriptions: clinical, economic and technical issues. Radiol Med. 2016;121(4):315–22. https://doi.org/10.1007/s11547-015-0606-1.

    CAS  Article  PubMed  Google Scholar 

  147. Gomez-Garcia JM, Gomez-Romero FJ, Arencibia-Jimenez M, Navarro-Gracia JF, Sanchez-Molla M. Appropriateness of magnetic resonance imaging requested by primary care physicians for patients with knee pain. Int J Qual Health Care. 2018;30(7):565–70. https://doi.org/10.1093/intqhc/mzy067.

    CAS  Article  PubMed  Google Scholar 

  148. Wright AA, Hegedus EJ, Lenchik L, Kuhn KJ, Santiago L, Smoliga JM. Diagnostic accuracy of various imaging modalities for suspected lower extremity stress fractures. Am J Sports Med. 2015;44(1):255–63.

    Article  PubMed  Google Scholar 

  149. Garras DN, Raikin SM, Bhat SB, Taweel N, Karanjia H. MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria. Clin Orthop Relat Res. 2012;470(8):2268–73. https://doi.org/10.1007/s11999-012-2355-y.

    Article  PubMed  PubMed Central  Google Scholar 

  150. Antoci V Jr, Patel SP, Weaver MJ, Kwon JY. Relevance of adjacent joint imaging in the evaluation of ankle fractures. Injury. 2016;47(10):2366–9. https://doi.org/10.1016/j.injury.2016.07.025.

    Article  PubMed  Google Scholar 

  151. Werner BC, Burrus MT, Kew ME, Dempsey IJ, Gwathmey FW, Miller MD, et al. Limited utility of routine early postoperative radiography after primary ACL reconstruction. Knee. 2016;23(2):237–40. https://doi.org/10.1016/j.knee.2015.09.006.

    Article  PubMed  Google Scholar 

  152. Jaecker V, Neumann L, Shafizadeh S, Koenen P, Kanakamedala AC, Tjardes T. Radiographic images are inapplicable for a precise evaluation of the femoral tunnel position following MPFL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3432–40. https://doi.org/10.1007/s00167-019-05378-6.

    Article  PubMed  Google Scholar 

  153. Jennewine B, Fiorino D, Kew M, Byrne A, Yarboro S. Routine postoperative radiographs after tibia plateau fixation have minimal impact on patient care. Injury. 2019;50(11):2093–6. https://doi.org/10.1016/j.injury.2019.07.025.

    CAS  Article  PubMed  Google Scholar 

  154. Longenecker AS, Kazarian GS, Boyer GP, Lonner JH. Radiographic imaging in the postanesthesia care unit is unnecessary after partial knee arthroplasty. J Arthroplasty. 2017;32(5):1431–3. https://doi.org/10.1016/j.arth.2016.11.033.

    Article  PubMed  Google Scholar 

  155. Moussa ME, Malchau H, Freiberg AA, Kwon YM. Effect of immediate postoperative portable radiographs on reoperation in primary total knee arthroplasty. Orthopedics. 2014;37(9):e817–21. https://doi.org/10.3928/01477447-20140825-59.

    Article  PubMed  Google Scholar 

  156. Sambandam SN, Khanna V, Rohinikumar G, Mounasamy V. Pre-discharge postoperative radiographs after primary total knee replacement: tradition or science? Acta Orthop Belg. 2017;83(1):132–9.

    CAS  PubMed  Google Scholar 

  157. Sheehan SE, Coburn JA, Singh H, Vanness DJ, Sittig DF, Moberg DP, et al. Reducing unnecessary shoulder MRI examinations within a capitated health care system: a potential role for shoulder ultrasound. J Am Coll Radiol. 2016;13(7):780–7. https://doi.org/10.1016/j.jacr.2016.03.015.

    Article  PubMed  Google Scholar 

  158. Freeman R, Khanna S, Ricketts D. Inappropriate requests for magnetic resonance scans of the shoulder. Int Orthop. 2013;37(11):2181–4. https://doi.org/10.1007/s00264-013-1968-4.

    Article  PubMed  PubMed Central  Google Scholar 

  159. Cortes A, Quinlan NJ, Nazal MR, Upadhyaya S, Alpaugh K, Martin SD. A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management. J Shoulder Elbow Surg. 2019;28(11):2153–60. https://doi.org/10.1016/j.jse.2019.04.003.

    Article  PubMed  Google Scholar 

  160. Feder OI, Levy BJ, Gruson KI. Routine plain radiographs in the setting of atraumatic shoulder pain: are they useful? J Am Acad Orthop Surg. 2018;26(8):287–93. https://doi.org/10.5435/JAAOS-D-16-00884.

    Article  PubMed  Google Scholar 

  161. Roberts S, Dearne R, Keen S, Littlewood C, Taylor S, Deacon P. Routine X-rays for suspected frozen shoulder offer little over diagnosis based on history and clinical examination alone. Musculoskelet Care. 2019;17(2):288–92. https://doi.org/10.1002/msc.1396.

    Article  Google Scholar 

  162. Karamitopoulos MS, Dean E, Littleton AG, Kruse R. Postoperative radiographs after pinning of supracondylar humerus fractures: are they necessary? J Pediatr Orthop. 2012;32(7):672–4. https://doi.org/10.1097/BPO.0b013e31824b2b37.

    Article  PubMed  Google Scholar 

  163. Dempsey IJ, Kew ME, Cancienne JM, Werner BC, Brockmeier SF. Utility of postoperative radiography in routine primary total shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26(7):e222–6. https://doi.org/10.1016/j.jse.2016.11.035.

    Article  PubMed  Google Scholar 

  164. Eastley N, Aujla R, Khan Z. Radiographs late in the follow up of uncomplicated distal radius fractures: are they worth it? Clinical outcome and financial implications. Orthop Rev (Pavia). 2012;4(2): e20. https://doi.org/10.4081/or.2012.e20.

    Article  Google Scholar 

  165. Sharma V, Witney-Lagen C, Cullen S, Kim E, Haider Z, Davy A, et al. The role of early post-operative radiographs following distal radius fracture fixation with a volar locking plate: time for change? J Hand Surg Asian Pac. 2019;24(4):435–9. https://doi.org/10.1142/S2424835519500553.

    Article  Google Scholar 

  166. Stone JD, Vaccaro LM, Brabender RC, Hess AV. Utility and cost analysis of radiographs taken 2 weeks following plate fixation of distal radius fractures. J Hand Surg Am. 2015;40(6):1106–9. https://doi.org/10.1016/j.jhsa.2015.02.013.

    Article  PubMed  Google Scholar 

  167. Van Gerven P, El Moumni M, Zuidema WP, Rubinstein SM, Krijnen P, Van Tulder MW, et al. Omitting routine radiography of traumatic distal radial fractures after initial 2-week follow-up does not affect outcomes. J Bone Joint Surg Am Vol. 2019;101(15):1342–50.

    Article  Google Scholar 

  168. Imerci A, Kaya A, Bozoglan M, Adam G, Canbek U, Savran A. Evaluation of computed tomography use in emergency department orthopedic trauma patients. Turk J Emerg Med. 2013;13(2):75–80.

    Article  Google Scholar 

  169. Chaudhry S, DelSole EM, Egol KA. Post-splinting radiographs of minimally displaced fractures: good medicine or medicolegal protection? J Bone Joint Surg Am. 2012;94(17): e128. https://doi.org/10.2106/JBJS.K.00944.

    Article  PubMed  Google Scholar 

  170. Michelotti BF, Mathews A, Chung KC. Appropriateness of the use of magnetic resonance imaging in the diagnosis and treatment of wrist soft tissue injury. Plast Reconstr Surg. 2018;141(2):410–9. https://doi.org/10.1097/PRS.0000000000004023.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  171. Stott S, Balogh ZJ. Postoperative computed tomography for articular fractures: a systematic review. J Orthop Trauma. 2017;31(1):56–61. https://doi.org/10.1097/BOT.0000000000000660.

    Article  PubMed  Google Scholar 

  172. Wilson RJ, Zumsteg JW, Hartley KA, Long JH, Mesko NW, Halpern JL, et al. Overutilization and cost of advanced imaging for long-bone cartilaginous lesions. Ann Surg Oncol. 2015;22(11):3466–73.