Evidenced-based radiology? A single-institution review of imaging referral appropriateness including monetary and dose estimates for inappropriate scans
There has been a year on year increase in imaging requests at our academic institution. The iRefer guidelines are produced by the Royal College of Radiologists in the UK and are designed to prevent inappropriate imaging and radiation exposure. They have been available to general practitioners and hospital physicians in Ireland since March 2015.
Our aims were to determine the proportion of inappropriate imaging referrals pre- and post-guideline introduction and to calculate the cost and dose estimates for inappropriate scans.
A retrospective review of 1124 radiographs was performed with reference to a validated audit template. Emergency department, in-patient, and general practitioner referrals were reviewed. Cost and cumulative dose estimates were calculated for inappropriate referrals taking into account salaries, average time spent performing/reporting radiographs, and median effective dose values.
The introduction of the iRefer guidelines has not significantly affected the proportion of inappropriate radiograph referrals at our institution, 42% pre-introduction and 43% post-introduction. We identified 784 inappropriate referrals across 6 radiograph subtypes, imparting a total median effective dose of 65.1 mSv to patients. The time spent performing inappropriate abdominal and spinal radiographs in 2017 yielded an estimated cost of €8036.40.
A significant amount of inappropriate radiographs continue to be requested and performed, exposing patients to needless ionizing radiation and wasting staff members time at a financial cost. Interventions are needed to decrease inappropriate referrals.
KeywordsImaging appropriateness iRefer guidelines Patient dose Radiology services
European Society of Radiology
Royal College of Radiologists
Health Service Executive
Clinical decision support
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human or animal participants performed by any of the authors.
- 4.HSE (2006) Health service executive code of governance: framework for the corporate and financial governance of the health service executive. https://https://www.hse.ie/eng/services/publications/corporate/codeofgovernance.pdf. Accessed 01 Dec 2018.
- 8.NHS (2014) Diagnostic imaging dataset annual statistical release 2013/14. https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostic-imaging-dataset/diagnostic-imaging-datasetdiagnostic-imaging-dataset-2013-14-data/. Accessed 01 Dec 2018
- 9.Culleton S, Torreggiani W (2014) Analysis of the last decade of weekend out-of-hours CT imaging: how have things changed? Ir Med J 107:77–79Google Scholar
- 10.Broder JS, Bhat R, Boyd JP, Ogloblin IA, Limkakeng A, Hocker MB, Drake WG, Miller T, Harringa JB, Repplinger MD (2016) Who explicitly requests the ordering of computed tomography for emergency department patients? A multicenter prospective study. Emerg Radiol 23:221–227. https://doi.org/10.1007/s10140-016-1382-5 CrossRefPubMedCentralGoogle Scholar
- 12.iRefer |. https://www.irefer.org.uk/. Accessed 19 Nov 2017
- 13.Audit of compliance with imaging referral guidelines | The Royal College of Radiologists. https://www.rcr.ac.uk/audit/audit-compliance-imaging-referral-guidelines. Accessed 20 Dec 2017
- 14.Patient Safety - Radiation Dose in X-Ray and CT Exams. https://www.radiologyinfo.org/en/info.cfm?pg=safety-xray. Accessed 17 Nov 2018
- 17.Sim EY, Tan DJA, Abdullah HR (2017) The use of computerized physician order entry with clinical decision support reduces practice variance in ordering preoperative investigations: a retrospective cohort study. Int J Med Inform 108:29–35. https://doi.org/10.1016/j.ijmedinf.2017.09.015 CrossRefGoogle Scholar
- 18.Holland K, McGeoch G, Gullery C (2017) A multifaceted intervention to improve primary care radiology referral quality and value in Canterbury. N Z Med J 130:55–64Google Scholar