European Radiology

, Volume 20, Issue 1, pp 1–15 | Cite as

Evidence-based radiology: why and how?

  • Francesco SardanelliEmail author
  • Myriam G. Hunink
  • Fiona J. Gilbert
  • Giovanni Di Leo
  • Gabriel P. Krestin
Health Economy



To provide an overview of evidence-based medicine (EBM) in relation to radiology and to define a policy for adoption of this principle in the European radiological community.


Starting from Sackett’s definition of EBM we illustrate the top-down and bottom-up approaches to EBM as well as EBM’s limitations. Delayed diffusion and peculiar features of evidence-based radiology (EBR) are defined with emphasis on the need to shift from the demonstration of the increasing ability to see more and better, to the demonstration of a significant change in treatment planning or, at best, of a significant gain in patient outcome. The “as low as reasonably achievable” (ALARA) principle is thought as a dimension of EBR while EBR is proposed as part of the core curriculum of radiology residency. Moreover, we describe the process of health technology assessment in radiology with reference to the six-level scale of hierarchy of studies on diagnostic tests, the main sources of bias in studies on diagnostic performance, and levels of evidence and degrees of recommendations according to the Centre for Evidence-Based Medicine (Oxford, UK) as well as the approach proposed by the GRADE working group. Problems and opportunities offered by evidence-based guidelines in radiology are considered. Finally, we suggest nine points to be actioned by the ESR in order to promote EBR.


Radiology will benefit greatly from the improvement in practice that will result from adopting this more rigorous approach to all aspects of our work.


Evidence-based medicine Evidence-based radiology ALARA Health technology assessment Degrees of recommendations 



We sincerely thank Professor Yves Menu (Department of Radiology, Saint Antoine Hospital, Paris) for his suggestions regarding the subsection “EBR at the ECR”.


  1. 1.
    Malone DE (2007) Evidence-based practice in radiology: an introduction to the series. Radiology 242:12–14CrossRefPubMedGoogle Scholar
  2. 2.
    Evidence-Based Radiology Working Group (2001) Evidence-based radiology: a new approach to the practice of radiology. Radiology 220:566–575CrossRefGoogle Scholar
  3. 3.
    Greenhalgh T (2006) How to read a paper. The basics of evidence-based medicine, 3rd edn. Blackwell, Oxford, pp ix–xiiGoogle Scholar
  4. 4.
    Greenhalgh T (2006) How to read a paper. The basics of evidence-based medicine, 3rd edn. Blackwell, Oxford, pp 1–3Google Scholar
  5. 5.
    Centre for Evidence-Based Medicine (2008) Accessed 24 Feb 2008
  6. 6.
    Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine: what it is and what it isn’t. BMJ 312:71–72PubMedGoogle Scholar
  7. 7.
    Hunink MGM, Glasziou PP, Siegel JE, Weeks JC, Pliskin JS, Elstein AS, Weinstein MC (2001) Decision making in health and medicine: integrating evidence and values. Cambridge University Press, Cambridge, UKGoogle Scholar
  8. 8.
    Malone DE, Staunton M (2007) Evidence-based practice in radiology: step 5 (evaluate)—caveats and common questions. Radiology 243:319–328CrossRefPubMedGoogle Scholar
  9. 9.
    Dodd JD (2007) Evidence-based practice in radiology: steps 3 and 4—appraise and apply diagnostic radiology literature. Radiology 242:342–354CrossRefPubMedGoogle Scholar
  10. 10.
    van Beek EJ, Malone DE (2007) Evidence-based practice in radiology education: why and how should we teach it? Radiology 243:633–640CrossRefPubMedGoogle Scholar
  11. 11.
    Hollingworth W, Jarvik JG (2007) Technology assessment in radiology: putting the evidence in evidence-based radiology. Radiology 244:31–38CrossRefPubMedGoogle Scholar
  12. 12.
    Trinder L (2000) A critical appraisal of evidence-based practice. In: Trinder L, Reynolds S (eds) Evidence-based practice: a critical appraisal. Blackwell Science, Oxford, pp 212–214Google Scholar
  13. 13.
    Tonelli MR (1998) The philosophical limits of evidence-based medicine. Acad Med 73:1234–1240CrossRefPubMedGoogle Scholar
  14. 14.
    Raymond J, Trop I (2007) The practice of ethics in the era of evidence-based radiology. Radiology 244:643–649CrossRefPubMedGoogle Scholar
  15. 15.
    Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J (1999) Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 318:527–530PubMedGoogle Scholar
  16. 16.
    Acheson L, Mitchell L (1993) The routine antenatal diagnostic imaging with ultrasound study. The challenge to practice evidence-based obstetrics. Arch Fam Med 2:1229–1231CrossRefPubMedGoogle Scholar
  17. 17.
    No authors listed (1997) Routine ultrasound imaging in pregnancy: how evidence-based are the guidelines? Int J Technol Assess Health Care 13:475–477Google Scholar
  18. 18.
    No authors listed (1997) Reports from the British Columbia Office of Health Technology Assessment (BCOHTA). Routine ultrasound imaging in pregnancy: how evidence-based are the guidelines? Int J Technol Assess Health Care 13:633–637Google Scholar
  19. 19.
    Dixon AK (1997) Evidence-based diagnostic radiology. Lancet 350:509–512CrossRefPubMedGoogle Scholar
  20. 20.
    Mukerjee A (1999) Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Magnetic resonance imaging in acute knee haemarthrosis. J Accid Emerg Med 16:216–217PubMedGoogle Scholar
  21. 21.
    Liedberg J, Panmekiate S, Petersson A, Rohlin M (1996) Evidence-based evaluation of three imaging methods for the temporomandibular disc. Dentomaxillofac Radiol 25:234–241PubMedGoogle Scholar
  22. 22.
    Taïeb S, Vennin P (2001) Evidence-based medicine: towards evidence-based radiology. J Radiol 82:887–890PubMedGoogle Scholar
  23. 23.
    Arrivé L, Tubiana JM (2002) “Evidence-based” radiology. J Radiol 83:661PubMedGoogle Scholar
  24. 24.
    Bui AA, Taira RK, Dionisio JD et al (2002) Evidence-based radiology: requirements for electronic access. Acad Radiol 9:662–669CrossRefPubMedGoogle Scholar
  25. 25.
    Guillerman RP, Brody AS, Kraus SJ (2002) Evidence-based guidelines for pediatric imaging: the example of the child with possible appendicitis. Pediatr Ann 31:629–640PubMedGoogle Scholar
  26. 26.
    Kainberger F, Czembirek H, Frühwald F, Pokieser P, Imhof H (2002) Guidelines and algorithms: strategies for standardization of referral criteria in diagnostic radiology. Eur Radiol 12:673–679PubMedGoogle Scholar
  27. 27.
    Bennett JD (2003) Evidence-based radiology problems. Covered stent treatment of an axillary artery pseudoaneurysm: June 2003–June 2004. Can Assoc Radiol J 54:140–143PubMedGoogle Scholar
  28. 28.
    Blackmore CC (2003) Evidence-based imaging evaluation of the cervical spine in trauma. Neuroimaging Clin N Am 13:283–291CrossRefPubMedGoogle Scholar
  29. 29.
    Cohen WA, Giauque AP, Hallam DK, Linnau KF, Mann FA (2003) Evidence-based approach to use of MR imaging in acute spinal trauma. Eur J Radiol 48:49–60CrossRefPubMedGoogle Scholar
  30. 30.
    Goergen SK, Fong C, Dalziel K, Fennessy G (2003) Development of an evidence-based guideline for imaging in cervical spine trauma. Australas Radiol 47:240–246CrossRefPubMedGoogle Scholar
  31. 31.
    Medina LS, Aguirre E, Zurakowski D (2003) Introduction to evidence-based imaging. Neuroimaging Clin N Am 13:157–165CrossRefPubMedGoogle Scholar
  32. 32.
    Blackmore CC (2004) Critically assessing the radiology literature. Acad Radiol 11:134–140CrossRefPubMedGoogle Scholar
  33. 33.
    Dodd JD, MacEneaney PM, Malone DE (2004) Evidence-based radiology: how to quickly assess the validity and strength of publications in the diagnostic radiology literature. Eur Radiol 14:915–922CrossRefPubMedGoogle Scholar
  34. 34.
    Erden A (2004) Evidence based radiology. Tani Girisim Radyol 10:89–91PubMedGoogle Scholar
  35. 35.
    Gilbert FJ, Grant AM, Gillan MGC (2004) Low back pain: influence of early MR imaging or CT on treatment and outcome—multicenter randomized trial. Radiology 231:343–351CrossRefPubMedGoogle Scholar
  36. 36.
    Matowe L, Gilbert FJ (2004) How to synthesize evidence for imaging guidelines. Clin Radiol 59:63–68CrossRefPubMedGoogle Scholar
  37. 37.
    Giovagnoni A, Ottaviani L, Mensà A et al (2005) Evidence based medicine (EBM) and evidence based radiology (EBR) in the follow-up of the patients after surgery for lung and colon-rectal carcinoma. Radiol Med 109:345–357PubMedGoogle Scholar
  38. 38.
    Medina LS, Blackmore CC (2006) Evidence-based imaging, 1st edn. Springer, New YorkGoogle Scholar
  39. 39.
    Medina LS, Blackmore CC (2007) Evidence-based radiology: review and dissemination. Radiology 244:331–336CrossRefPubMedGoogle Scholar
  40. 40.
    Royal College of Radiologists Working Party (1998) Making the best use of a department of clinical radiology: guidelines for doctors, 4th edn. The Royal College of Radiologists, LondonGoogle Scholar
  41. 41.
    No authors listed (2004) Proceedings of the second ALARA conference. February 28, 2004. Houston, Texas, USA. Pediatr Radiol 34(Suppl 3):S162–S246Google Scholar
  42. 42.
    Prasad KN, Cole WC, Haase GM (2004) Radiation protection in humans: extending the concept of as low as reasonably achievable (ALARA) from dose to biological damage. Br J Radiol 77:97–99CrossRefPubMedGoogle Scholar
  43. 43.
    Semelka RC, Armao DM, Elias J Jr, Huda W (2007) Imaging strategies to reduce the risk of radiation in CT studies, including selective substitution with MRI. J Magn Reson Imaging 25:900–909CrossRefPubMedGoogle Scholar
  44. 44.
    Council of the European Union (1997) Council Directive 97/43/Euratom of 30 June 1997 on health protection of individuals against the dangers of ionizing radiation in relation with medical exposure, and repealing Directive 84/466/Euratom. J Eur Commun L 180:22–27 ( Scholar
  45. 45.
    Barr HJ, Ohlhaber T, Finder C (2006) Focusing in on dose reduction: the FDA perspective. AJR Am J Roentgenol 186:1716–1717CrossRefPubMedGoogle Scholar
  46. 46.
    FDA Radiological Health Program (2008) Available via: Accessed 24 Feb 2008
  47. 47.
    White SJ, Ashby D, Brown PJ (2000) An introduction to statistical methods for health technology assessment. Health Technol Assess 4(i–iv):1–59Google Scholar
  48. 48.
    Hillman BJ, Gatsonis CA (2008) When is the right time to conduct a clinical trial of a diagnostic imaging technology? Radiology 248:12–15CrossRefPubMedGoogle Scholar
  49. 49.
    Fineberg HV, Bauman R, Sosman M (1977) Computerized cranial tomography. Effect on diagnostic and therapeutic plans. JAMA 238:224–227CrossRefPubMedGoogle Scholar
  50. 50.
    Fryback DG, Thornbury JR (1991) The efficacy of diagnostic imaging. Med Decis Making 11:88–94CrossRefPubMedGoogle Scholar
  51. 51.
    Thornbury JR (1994) Clinical efficacy of diagnostic imaging: love it or leave it. AJR Am J Roentgenol 162:1–8PubMedGoogle Scholar
  52. 52.
    Mackenzie R, Dixon AK (1995) Measuring the effects of imaging: an evaluative framework. Clin Radiol 50:513–518CrossRefPubMedGoogle Scholar
  53. 53.
    Thornbury JR (1999) Intermediate outcomes: diagnostic and therapeutic impact. Acad Radiol 6(suppl 1):S58–S65CrossRefPubMedGoogle Scholar
  54. 54.
    Sunshine JH, Applegate KE (2004) Technology assessment for radiologists. Radiology 230:309–314CrossRefPubMedGoogle Scholar
  55. 55.
    Brealey SD, DAMASK (Direct Access to Magnetic Resonance Imaging: Assessment for Suspect Knees) Trial Team (2007) Influence of magnetic resonance of the knee on GPs’ decisions: a randomised trial. Br J Gen Pract 57:622–629PubMedGoogle Scholar
  56. 56.
    Oei EH, Nikken JJ, Ginai AZ, From the Program for the Assessment of Radiological Technology (ART Program) et al (2009) Costs and effectiveness of a brief MRI examination of patients with acute knee injury. Eur Radiol 19(2):409–418CrossRefPubMedGoogle Scholar
  57. 57.
    Ouwendijk R, de Vries M, Stijnen T, from the Program for the Assessment of Radiological Technology et al (2008) Multicenter randomized controlled trial of the costs and effects of noninvasive diagnostic imaging in patients with peripheral arterial disease: the DIPAD trial. AJR Am J Roentgenol 190:1349–1357CrossRefPubMedGoogle Scholar
  58. 58.
    Kuhl CK, Träber F, Schild HH (2008) Whole-body high-field-strength (3.0-T) MR imaging in clinical practice. Part I. Technical considerations and clinical applications. Radiology 246:675–696CrossRefPubMedGoogle Scholar
  59. 59.
    Jordan HS, Bert RB, Chew P, Kupelnick B, Lau J (2003) Magnetic resonance spectroscopy for brain tumors. Agency for Healthcare Research and Quality, Rockville, p 109Google Scholar
  60. 60.
    Möller-Hartmann W, Herminghaus S, Krings T et al (2002) Clinical application of proton magnetic resonance spectroscopy in the diagnosis of intracranial mass lesions. Neuroradiology 44:371–381CrossRefPubMedGoogle Scholar
  61. 61.
    Soares HP, Kumar A, Daniels S et al (2005) Evaluation of new treatments in radiation oncology: are they better than standard treatments? JAMA 293:970–978CrossRefPubMedGoogle Scholar
  62. 62.
    Hunink MG, Krestin GP (2002) Study design for concurrent development, assessment, and implementation of new diagnostic imaging technology. Radiology 222:604–614CrossRefPubMedGoogle Scholar
  63. 63.
    Jarvik JG (2002) Study design for the new millennium: changing how we perform research and practice medicine. Radiology 222:593–594CrossRefPubMedGoogle Scholar
  64. 64.
    Launois R (2003) Economic assessment, a field between clinical research and observational studies. Bull Cancer 90:97–104PubMedGoogle Scholar
  65. 65.
    Plevritis SK (2005) Decision analysis and simulation modeling for evaluating diagnostic tests on the basis of patient outcomes. AJR Am J Roentgenol 185:581–590PubMedGoogle Scholar
  66. 66.
    Otero HJ, Rybicki FJ, Greenberg D, Neumann PJ (2008) Twenty years of cost-effectiveness analysis in medical imaging: are we improving? Radiology 249:917–925CrossRefPubMedGoogle Scholar
  67. 67.
    Hunink MG (2008) Cost-effectiveness analysis: some clarifications. Radiology 249:753–755CrossRefPubMedGoogle Scholar
  68. 68.
    Sardanelli F, Di Leo G (2008) Biostatistics for radiologists. Springer, Milan, pp 165–179Google Scholar
  69. 69.
    Kelly S, Berry E, Roderick P et al (1997) The identification of bias in studies of the diagnostic performance of imaging modalities. Br J Radiol 70:1028–1035PubMedGoogle Scholar
  70. 70.
    Sica GT (2006) Bias in research studies. Radiology 238:780–789CrossRefPubMedGoogle Scholar
  71. 71.
    Reid MC, Lachs MS, Feinstein AR (1995) Use of methodological standards in diagnostic test research. Getting better but still not good. JAMA 274:645–651CrossRefPubMedGoogle Scholar
  72. 72.
    Bossuyt PM, Reitsma JB, Bruns DE et al (2003) Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Radiology 226:24–28CrossRefPubMedGoogle Scholar
  73. 73.
    Smidt N, Rutjes AW, van der Windt DA et al (2005) Quality of reporting of diagnostic accuracy studies. Radiology 235:347–353CrossRefPubMedGoogle Scholar
  74. 74.
    Wilczynski NL (2008) Quality of reporting of diagnostic accuracy studies: no change since STARD statement publication—before-and-after study. Radiology 248:817–823CrossRefPubMedGoogle Scholar
  75. 75.
    Moher D, Schulz KF, Altman DG (2001) The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 357:1191–1194CrossRefPubMedGoogle Scholar
  76. 76.
    Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P, CONSORT Group (2008) Methods and processes of the CONSORT Group: example of an extension for trials assessing nonpharmacologic treatments. Ann Intern Med 148:W60–W66PubMedGoogle Scholar
  77. 77.
    Moher D, Cook DJ, Eastwood S et al (1999) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of reporting of meta-analyses. Lancet 354:1896–1900CrossRefPubMedGoogle Scholar
  78. 78.
    Atkins D, Best D, Briss PA, for the GRADE working group et al (2004) Grading quality of evidence and strength of recommendations. BMJ 328:1490 ( Scholar
  79. 79.
    Schünemann HJ, Oxman AD, Brozek J, for the GRADE Working Group et al (2008) Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ 336:1106–1110CrossRefPubMedGoogle Scholar
  80. 80.
    Field MJ, Lohr KN, eds (1992) Guidelines for clinical practice: from development to use. National Academy, Washington DCGoogle Scholar
  81. 81.
    Lohr KN (1992) Reasonable expectations: from the Institute of Medicine. Interview by Paul M Schyve. QRB Qual Rev Bull 18:393–396PubMedGoogle Scholar
  82. 82.
    Hurwitz B (1999) Legal and political considerations of clinical practice guidelines. BMJ 318:661–664PubMedGoogle Scholar
  83. 83.
    Shekelle PG, Woolf SH, Eccles M, Grimshaw J (1999) Clinical guidelines: developing guidelines. BMJ 318:593–596PubMedGoogle Scholar
  84. 84.
    Schmidt HG, van der Arend A, Moust JH, Kokx I, Boon L (1993) Influence of tutors’ subject-matter expertise on student effort and achievement in problem-based learning. Acad Med 68:784–791CrossRefPubMedGoogle Scholar
  85. 85.
    Royal College of Radiologists (2007) Making the best use of clinical radiology services (MBUR), 6th edn. Accessed 21 June 2009
  86. 86.
    American College of Radiologists (2009) Guidelines available at: Accessed 21 June 2009
  87. 87.
    Canadian Association of Radiologists (2009) Guidelines available at: Accessed 21 June 2009
  88. 88.
  89. 89.
    Cabana MD, Rand CS, Powe NR et al (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465CrossRefPubMedGoogle Scholar
  90. 90.
    Tigges S, Sutherland D, Manaster BJ (2000) Do radiologists use the American College of Radiology musculoskeletal appropriateness criteria? AJR Am J Roentgenol 175:545–547PubMedGoogle Scholar
  91. 91.
    The European Network for the Assessment of Imaging in Medicine (EuroAIM) (2009) Accessed 21 June 2009
  92. 92.
    Appraisal of Guidelines Research and Evaluation (AGREE) Accessed 21 June 2009

Copyright information

© European Society of Radiology 2009

Authors and Affiliations

  • Francesco Sardanelli
    • 1
    Email author
  • Myriam G. Hunink
    • 2
    • 3
    • 4
  • Fiona J. Gilbert
    • 5
  • Giovanni Di Leo
    • 1
  • Gabriel P. Krestin
    • 2
  1. 1.Dipartimento di Scienze Medico-Chirurgiche, Unità di Radiologia, IRCCS Policlinico San DonatoUniversità degli Studi di MilanoMilanItaly
  2. 2.Department of RadiologyErasmus University Medical CenterRotterdamThe Netherlands
  3. 3.Department of EpidemiologyErasmus University Medical CenterRotterdamThe Netherlands
  4. 4.Program for Health Decision ScienceHarvard School of Public HealthBostonUSA
  5. 5.Aberdeen Biomedical Imaging CentreUniversity of AberdeenAberdeenUK

Personalised recommendations