Evidenced-based radiology? A single-institution review of imaging referral appropriateness including monetary and dose estimates for inappropriate scans

  • James W. RyanEmail author
  • Aoife Hollywood
  • Aaron Stirling
  • Martina Glynn
  • Peter J. MacMahon
  • Ferdia Bolster
Original Article



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.


Imaging appropriateness iRefer guidelines Patient dose Radiology services 



European Society of Radiology


Royal College of Radiologists


United Kingdom


Health Service Executive


General practitioner


Para-nasal sinus


Nasal bone


Abdominal radiographs


Emergency department




Spinal radiograph


Clinical decision support




Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human or animal participants performed by any of the authors.


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Copyright information

© Royal Academy of Medicine in Ireland 2019

Authors and Affiliations

  1. 1.Mater Misericordiae University HospitalDublinIreland

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