Abstract
Background and Objective
Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20–50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide.
Methods
This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive.
Results
Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients.
Conclusions
This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Low-value imaging, imaging not affecting the patients’ further care and treatment, occupies resources in healthcare that could be used for high-value services. |
The cost of low-value imaging could amount to billions of US dollars per year. |
Measures for reducing low-value imaging are needed at all levels of healthcare. |
1 Introduction
Diagnostic imaging is an essential part of modern patient management at all levels of healthcare [1]. The use and expenditures of healthcare services, including imaging, are increasing worldwide [1, 2]. According to the WHO, 3.6 billion imaging examinations are conducted each year, and 250 million of these are of children under the age of 15 years [3]. About 84% of examinations worldwide are conventional radiography and fluoroscopy (CR), while 8% are computed tomography (CT), about 4% ultrasound (US), 3% magnetic resonance imaging (MRI), and 1% nuclear medicine (NM) [4,5,6,7].
According to the Organization for Economic Co-operation and Development, 10‒34% of healthcare spending is wasteful and inappropriate [8]. Correspondingly, 20‒50% of imaging examinations have been reported to be inappropriate or of low value [8,9,10,11]. Low-value care is defined as services that provide little or no benefit to patients, have the potential to cause harm to patients, or waste limited healthcare resources [12]. Diagnostic imaging would be of low value when the examination has little or no impact on the management of the individual patient. Accordingly, it should not be confused with a negative examination result that might be valuable for ruling out serious conditions and preventing further health expenditures. From a societal perspective, low-value imaging constitutes increasing costs, while for the patient, it is an unnecessary risk due to exposure to ionizing radiation and/or contrast media [8,9,10,11]. Low-value imaging can be found across all imaging modalities [13], as well as in several patient groups [14], and is recognized as a major problem [1, 15]. Accordingly, recommendations, guidelines, and other measures have been issued to reduce its use. However, these measures often have a low impact on clinical practice as many barriers to reducing low-value services have been identified [16,17,18,19,20,21,22].
Imaging is a costly health service, and the number of examinations is rising [1]. Furthermore, in many countries, there is a lack of radiologists; thus, imaging could be a bottleneck in the healthcare system [1]. Low-value imaging examinations constitute a risk to patients, can reduce access to high-value care or delay crucial care, and result in poorer outcomes representing substantial opportunity costs.
Therefore, it is necessary to reduce the number of inappropriate or low-value examinations to free resources for high-value patient care. To do so, we need to know the resources used for low-value imaging. Accordingly, the objective of this systematic review was to provide an overview of the cost of low-value imaging worldwide.
2 Methods
This systematic review was conducted based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The database search was developed in Medline—Ovid and further adapted to Embase-Ovid, Cochrane Library, and Scopus. The search terms were built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse/Medical overuse, and Healthcare cost. Keywords were used for the concepts reduce/avoid and cost reduction. The complete search strategy and findings log can be found in the Online Supplementary Material (OSM) File 1. Searches were carried out in March 2022 with the last search on 15 March 2022. The search period was from 2012 to 2022 for the 10-year period in coherence with the activity of the choosing wisely campaign. Language filters were used to exclude papers written in languages other than English, German, Danish, Norwegian, and Swedish as these are the languages the authors are familiar with. Keywords were used to exclude studies on animals, mass screening, deep learning, other types of waste, or unnecessary care besides imaging.
2.1 Eligibility Criteria
Primary empirical studies assessing the costs of low-value diagnostic imaging were included. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis and cost-effectiveness analysis, and mixed-methods studies were included. The reference lists of relevant systematic reviews and meta-analyses were hand-searched for additional primary studies eligible for inclusion.
2.2 Selection of Records and Methodological Quality Appraisal
The records were archived using the Thomson Reuters EndNote X9.3.3 library, and duplicates were removed. All remaining records were transferred to Rayyan QCRI where additional duplicates were removed. All authors participated in the title and abstract screening using Rayyan. During the screening, records marked “Maybe” were discussed among the authors to agree on whether to include or reject them. All authors contributed to the full-text review and quality assessment of the studies. Due to the different methodologies of the included studies, the JBI critical appraisal tool was used for methodological quality assessment [23]. Any disagreements during abstract or full-text screening were resolved through discussion and consensus. During the full-text screening, reference lists of included articles were hand-searched for relevant articles. Google Scholar was used for hand searching for eligible papers that cited the included studies.
2.3 Data Extraction and Analysis
Data extraction was completed using a standardized summary table consisting of the following categories: author, title and year, country, design/methods, population, clinical setting, clinical indication for imaging, imaging modality, low-value imaging examination, control or comparator, cost/cost reduction, currency, the year costs were calculated, and cost denomination. All authors contributed to the data extraction. In addition, data extraction was discussed by the research team for quality assurance purposes.
Meta-analysis or comparison between studies or countries was not performed as reported costs are calculated differently in different studies, ranging from modeling to direct cost calculation. Just the cost of the index imaging study is included in the current review. For all results, the monetary value was converted to July 2022 US dollars using online converter calculators (https://www.oanda.com/currency-converter/en/?from=EUR&to=USD&amount=1) to provide an overview of costs in general. In studies where the year of cost calculation was not explicitly stated, we assumed the year costs were calculated was the same as the publication year.
3 Results
A total of 5,567 records were identified through database searches. 1,985 duplicates were removed, and 3,582 titles and abstracts were screened (Fig. 1). Hand-searching techniques resulted in the screening of 18 additional full-text records. In total, 166 reports were assessed for eligibility in full text, and of these, 60 records were excluded during full-text screening (OSM File 2 gives an overview of reasons for exclusion). In total, 106 studies were included in this review.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram of selection of studies
The quality assessment, based on the JBI critical appraisal tool, resulted in no exclusion based on methodological issues, even though the quality of studies varied. Five types of checklists were used: RCT, cohort study, analytical cross-sectional studies, cost analysis, and quasi-experimental appraisal tools, depending on the design of the appraised study. The result of the quality appraisal is available in OSM File 3.
3.1 Characteristics of Included Studies
Table 1 presents the characteristics of the 106 included studies. Most studies employed a retrospective chart review/cohort design (n = 76), while six used a cross-sectional design. Another six studies were cost-effectiveness or cost analysis studies using modeling. The last 18 studies used different methodologies, from randomized controlled trials (n = 1) to mixed methods (n = 1). Most of the studies were conducted in the USA (n = 70), 17 studies were conducted in European countries, seven in Canada, five in Australia, and seven in other parts of the world, mainly Asian countries. The settings of most included studies were hospitals or medical centers (n = 82), while eight studies used multiple settings, and six were from an emergency department setting. Other settings included primary care/hospice (n = 4), intensive care unit (n = 4), and imaging center (n = 2).
Sixty-eight studies assessed a single imaging modality, CR (n = 32), MRI (n = 15), CT (n = 11), US (n = 8), and NM (n = 2), while 38 studies assessed the costs of multiple imaging modalities.
3.2 Cost of Low-Value Imaging
Sixteen studies reported on the aggregated costs of low-value imaging or possible annual cost reduction, illustrating the amount of healthcare resources spent on imaging without impact on patient management. An overview of the individual studies is presented in Table 2. The possible cost reduction or costs reported varies between setting and patient groups. However, the possible redistribution of resources would be worth billions of dollars globally.
Based on the reported cost per examination of the included studies an overview per modality is presented in Table 3, both in terms of overall cost per modality and with examples of specific patient groups. Costs vary based on cost level in different countries and imaging techniques, for example, in MRI number of sequences and use of contrast media [22, 24, 26,27,28,29,30,31,32,33,34, 37,38,39,40,41,42,43,44, 46, 47, 50,51,52,53, 55,56,57,58, 60, 61, 63,64,65,66,67,68,69,70,71,72,73,74,75, 77,78,79,80,81,82,83,84,85,86,87,88,89,90,91, 95, 96, 99, 102, 104, 106,107,108,109,110, 112,113,114, 117,118,119,120,121,122,123,124,125,126].
Low-value CR imaging in the included studies was mostly routine use of musculoskeletal or chest x-rays (CXR) in pre-/post-operative follow-up examinations. However, mammography, angiography, gastrointestinal imaging, and bone density scans used routinely or in follow-up were also included [22, 24, 26,27,28,29,30,31,32,33,34, 37, 38, 40,41,42,43,44, 46, 47, 50,51,52,53, 91, 99, 102, 104, 109, 110, 113, 119, 122,123,124,125].
For CT and MRI, oncology, orthopedic, cardiovascular, and neurology patients were the dominating patient groups included, with routine examinations or imaging non-compliant with guidelines dominating the findings [55,56,57,58, 60, 61, 63,64,65, 74, 75, 77,78,79,80,81,82,83,84,85,86,87,88, 91, 95, 96, 99, 102, 104, 106,107,108,109,110, 112,113,114, 117,118,119,120,121,122,123,124,125,126].
In US, examinations in oncology and cardiovascular diseases were most common amongst the included studies [66,67,68,69,70,71, 73, 91, 95, 96, 104, 109, 112, 118, 119, 121, 123], while in NM, examinations for oncology patients were most common [89, 90, 95, 104, 108, 110, 111, 118, 120, 122, 123].
3.3 Possible Cost Reduction Through Initiatives in Practice
Four studies, including cost-reduction calculations of interventions to reduce the use of low-value imaging, showed that costs of lower back pain imaging could be reduced by 95% in Australia [115, 116], 73–83% in the USA [128], and up to 16% in Belgium without harm to patients [97]. When introducing an intervention to reduce the routine/daily use of CXR in the ICU, four studies showed a cost reduction of 20‒66% without affecting quality of care [25, 35, 36, 54]. Furthermore, the reduction of preoperative routine CXR reduced costs by 88% in one study [45]. For X-rays of ankle injuries, two studies found that using the guidelines could reduce costs by 7‒49% [48, 93]. One RCT study examining a simplified radiography follow-up regime after stable fracture fixations demonstrated a cost reduction of 65% [49]. Four studies, two in a hospital/Emergency Department setting [100, 105] and two specifically in trauma patients [62, 92] assessed the use of health information exchange to reduce imaging examinations. In trauma patients, a 37‒47% cost reduction was shown, while the changes in cost were small in the overall use of imaging, as some examinations increased in use while others were reduced. Other studies on various patient groups showed 34‒70% cost reduction [59, 94, 127, 128].
4 Discussion
This study is the first systematic review of the costs of low-value imaging globally. Given the universal challenges with resource allocation, this represents a vast opportunity cost and a great potential for providing high-quality services and improving the quality of care. Variation in access and use of imaging is found between and within countries and regions, indicating overuse in some areas and underuse in others. Low-value imaging is most common in areas with easy service access [129,130,131,132,133,134]. Thus, the potential opportunity cost and potential for improvement of the quality of services will vary.
Earlier research has identified specific clinical indications where low-value imaging is more prominent, such as atraumatic pain and routine imaging in minor head injuries, urolithiasis, trauma, thrombosis, and follow-ups [14]. This review demonstrates that some initiatives for reducing low-value imaging yield substantial cost reduction, as costs for low-value lower back pain imaging could be reduced by 95%, and preoperative routine CXR costs could be reduced by 88%. At the same time, other initiatives demonstrated less cost reduction (< 20%). Thus, some types of imaging have a higher potential for reducing costs, or there are differences in the success rate of the chosen intervention. The right combination of imaging to target and type of intervention can free resources for other high-value services, both in imaging and in other parts of the health services, by reducing cascaded unnecessary care [135]. This will improve the quality and efficiency of care and could help reduce healthcare emissions [136].
A systematic review of measures for reducing low-value imaging found that most initiatives focus on implementing guidelines and training referrers to reduce the number of inappropriate referrals to imaging [137], and that most initiatives target musculoskeletal, neuro, and vascular imaging. Several of the initiatives succeeded in reducing the use of imaging, at least for a short time. However, initiatives may need to target other parts of the health services than the referrer alone. To create sustainable change, it will be important to target low-value health service drivers broadly. As shown by Landon et al. [138], drivers of low-value services are complex and can be found at all levels: hospital, provider, and patient. Financial incentives, culture in the medical community, and intensity of care are especially strong drivers. Hence, measures addressing drivers on all levels of healthcare and imaging services are needed to tackle the challenge of low-value imaging.
Furthermore, some examinations are more resource intensive. For example, MRI and NM represent 3% and 1% of the total imaging volume, respectively. However, they have the highest overall costs per examination. This can be explained by the high costs of these examinations and the status and imperative of hi-tech imaging [139, 140]. Therefore, reducing low-value utilization of such examinations may result in great resources freed for high-value care.
4.1 Strengths and Limitations
As with all systematic reviews, this study depends on the content and quality of the included studies. According to our assessment, the quality of the studies varied, and results reported are thus of variable quality as well. In addition, the methodology used in the studies for calculating costs varied greatly. While some studies reported on thorough cost analysis, many reported costs as part of an overall objective, for example, estimates on cost reduction from a measure implemented at the hospital. Moreover, many different sources of cost data were used, such as direct and indirect cost calculations, fees, price lists at hospitals, or reimbursement amounts, permitting a large variation in reported costs. However, cost levels vary between healthcare systems and countries worldwide, which may be mirrored in the included studies. Furthermore, countries with underuse are possibly under-represented in this study but are also much less likely to have high rates of low-value care. Correspondingly, cost estimates are based on studies from countries that have documented higher rates of low-value imaging. The bias in the publications on cost may represent a “natural weighting” of the extent of low-value imaging as there are more publications from areas that are more concerned about low-value imaging and its opportunity cost.
As pointed out in the Methods section (Sect. 2), we estimated the year of cost calculation (publication year) for studies lacking adequate information. This may not be correct. However, the resulting errors may be small, as the yearly cost changes are small. For the proportion of low-value imaging, there may be relevant differences for the various modalities. Further, analysis is not possible based on this data set, however points to knowledge gaps urgently needing to be filled by further research.
Finally, a strength of this study is the use of the costs of specific low-value imaging examinations and not for imaging in general. Thus, the costs of low-value examinations were in all probability identified through this search strategy. In addition, while low-value care is a well-defined area in general, the efforts to reduce low-value healthcare have been hampered by the lack of consensus around a single definition for “value.” For example, imaging can be seen as valuable to calm people’s anxiety, i.e., due to its anxiolytic effect. In this review we have only considered direct, intended, and documented health effects as valuable. Moreover, we have, as has been suggested elsewhere [141, 142], included economic values in assessing low-value care.
5 Conclusions
This review documents the costs of low-value imaging amounts to billions of dollars worldwide and demonstrates vast opportunity costs and great potential to improve the quality and efficiency of health services. This potential will be greatest in areas with high utilization of low-value imaging. Drivers of low-value imaging should be addressed at all levels of healthcare to reduce low-value imaging and expedite access to high-value imaging. Hence, more knowledge is needed on costs, specific drivers, and effective measures for reducing low-value imaging and improving the quality of care.
References
Brady AP, Bello JA, Derchi LE, Fuchsjäger M, Goergen S, Krestin GP, et al. Radiology in the era of value-based healthcare: a multi-society expert statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA. Radiology. 2021;298:486–91.
European Commission. Defining value in ‘value-based healthcare’: opinion by the Expert Panel on effective ways of investing in Health (EXPH). Publications Office; 2019.
World health organization. To X-ray or not to X-ray? [Internet]. 2022. https://www.who.int/news-room/feature-stories/detail/to-x-ray-or-not-to-x-ray. Accessed 01 Aug 2023.
Lakrimi M. Magnetic Resonance Imaging (MRI) and its global impact in healthcare [Internet]. 2018. https://www.researchgate.net/publication/331563555_Magnetic_Resonance_Imaging_MRI_and_its_global_impact_in_healthcare/references. Accessed 20 Apr 2023.
NHS. Diagnostic Imaging Dataset Annual Statistical Release 2017/18 [Internet]. England; 2019. https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2018/11/Annual-Statistical-Release-2017-18-PDF-1.6MB-1.pdf. Accessed 01 Aug 2023.
Schöckel L, Jost G, Seidensticker P, Lengsfeld P, Palkowitsch P, Pietsch H. Developments in X-ray contrast media and the potential impact on computed tomography. Invest Radiol. 2020;55:592–7.
World Nuclear Association. Radioisotopes in Medicine [Internet]. 2022. https://world-nuclear.org/information-library/non-power-nuclear-applications/radioisotopes-research/radioisotopes-in-medicine.aspx. Accessed 03 Aug 2023.
Socha K, Couffinhal A, Forde I, Nader C, Cecchini M, Lee S, et al. Tackling wasteful spending on health [Internet]. Paris: OECD Publishing; 2017. https://doi.org/10.1787/9789264266414-en.
Hendee WR, Becker GJ, Borgstede JP, Bosma J, Casarella WJ, Erickson BA, et al. Addressing overutilization in medical imaging. Radiology. 2010;257:240–5.
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;13:1079–82.
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;13:131–6.
Colla CH. Swimming against the current—what might work to reduce low-value care? N Engl J Med. 2014;371:1280–3.
Rao VM, Levin DC. The overuse of diagnostic imaging and the Choosing Wisely initiative. Ann Intern Med. 2012;157:574–6.
Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, Van Bodegom-Vos L, Clement FM, et al. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging. 2022;22:73.
Levin DC, Rao VM. Reducing inappropriate use of diagnostic imaging through the choosing wisely initiative. J Am Coll Radiol. 2017;14:1245–52.
Hong AS, Hong DR-D, Zhang F, Frank Wharam J. Small decline in low-value back imaging associated with the ‘Choosing Wisely’ campaign. Health Aff. 2017;36:671–9.
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 (CCLM). 2016;54:1133–9.
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;58:269–74.
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;18:821–9.
Mafi JN, Reid RO, Baseman LH, Hickey S, Totten M, Agniel D, et al. Trends in Low-value health service use and spending in the Us Medicare Fee-for-Service Program, 2014–2018. JAMA Netw Open. 2021;4:e2037328–e2037328.
Rosenberg A, Agiro A, Gottlieb M, Barron J, Brady P, Liu Y, et al. Early trends among seven recommendations from the choosing wisely campaign. JAMA Intern Med. 2015;175:1913–20.
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;188:1385–9.
Moola S MZ Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P, Lisy K, Mu PF. Chapter 7: systematic reviews of etiology and risk in JBI manual for evidence synthesis [Internet]. JBI; 2020. https://synthesismanual.jbi.global. Accessed 23 Jun 2023.
Birir A, Amen TB, Varady NH, Chen AF. Clinical efficacy and cost-effectiveness of postoperative radiographs after total knee arthroplasty. Knee. 2021;32:97–102.
Brogi E, Bignami E, Sidoti A, Shawar M, Gargani L, Vetrugno L, et al. Could the use of bedside lung ultrasound reduce the number of chest x-rays in the intensive care unit? Cardiovasc Ultrasound. 2017;15:23–23.
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 6,875 patients. Chest. 2018;154:148–56.
Crawford EJ, Pincus D, Camp MW, Coyte PC. Cost savings of implementing the SickKids Paediatric Orthopaedic Pathway for proximal humerus fractures in Ontario, Canada. Paediatr Child Health. 2018;23:e109–16.
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:e222–6.
Diaz Vico T, Elli EF. Utility of immediate postoperative upper gastrointestinal contrast study in bariatric surgery. Obes Surg. 2019;29:1130–3.
Feng TS, Perkins CE, Wood LN, Eilber KS, Wang JK, Bresee C, et al. Preoperative testing for urethral sling surgery for stress urinary incontinence: overuse, underuse and cost implications. J Urol. 2016;195:120–4.
Gil-Borrelli CC, Agusti S, Pla R, Diaz-Redondo A, Zaballos M. Economic impact of clinical variability in preoperative testing for major outpatient surgery. Impacto economico de la variabilidad clinica en la peticion de pruebas preoperatorias en cirugia mayor ambulatoria. 2016;94:280–6.
Izamin I, Rizal AMM. Chest X-ray as an essential part of routine medical examination: is it necessary? Med J Malays. 2012;67:606–9.
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;50:2093–6.
Kempegowda H, Richard R, Borade A, Tawari A, Howenstein AM, Kubiak EN, et al. The role of radiographs and office visits in the follow-up of healed intertrochanteric hip fractures: an economic analysis. J Orthopaedic Trauma. 2016;30:687–90.
Keveson B, Clouser RD, Hamlin MP, Stevens PMSNRN, Stinnett-Donnelly JM, Allen GB. Adding value to daily chest X-rays in the ICU through education, restricted daily orders and indication-based prompting. BMJ Open Qual. 2017;6: e000072.
Ko A, Murry JS, Hoang DM, Harada MY, Aquino L, Coffey C, et al. High-value care in the surgical intensive care unit: effect on ancillary resources. J Surg Res. 2016;202:455–60.
Ling S-NJ, Cleary AJ. Are unnecessary serial radiographs being ordered in children with distal radius buckle fractures? Radiol Res Pract. 2018;2018:5143639.
Longenecker AS, Kazarian GS, Boyer GP, Lonner JH. Radiographic imaging in the postanesthesia care unit is unnecessary after partial knee arthroplasty. J Arthroplasty. 2017;32:1431–3.
Maldonado S, Hi N, Ha T, Choi P, Khalkhali I, Kalantari BN, et al. Utility of short-interval follow-up mammography after a benign-concordant stereotactic breast biopsy result. Breast. 2018;42:50–3.
McCabe RM, Grainger M, Davis J. Routine in-hospital radiographs following anterior cervical discectomy and fusion surgery: neither necessary nor cost-effective? Cureus. 2021;13: e19975.
McGrath E, Ranstrom L, Lajoie D, McGlynn L, Mooney D. Is a chest radiograph required after removal of chest tubes in children? J Pediatr Health Care. 2017;31:588–93.
Morden NE, Schpero WL, Zaha R, Sequist TD, Colla CH. Overuse of short-interval bone densitometry: assessing rates of low-value care. Osteopor Int. 2014;25:2307–11.
Porter ED, Kelly JL, Fay KA, Hasson RM, Millington TM, Finley DJ, et al. Reducing unnecessary chest X-ray films after thoracic surgery: a quality improvement initiative. Ann Thorac Surg. 2021;111:1012–8.
Rafiq MS, Rafiq M, Rafiq MI, Salman SG, Hafeez S. Doing Pre-operative investigations in emergency department; a clinical audit. Emergency (Tehran, Iran). 2017;5: e20.
Richards SE, Shiffermiller JF, Wells AD, May SM, Chakraborty S, Caverzagie KJ, et al. A clinical process change and educational intervention to reduce the use of unnecessary preoperative tests. J Grad Med Educ. 2014;6:733–7.
Sanchez Morales D, Borade A, Serrano-Riera R, Maniar HH, Sanders RW, Horwitz DS. Potential economic benefits of limited clinical and radiographic follow-up after plate fixation of midshaft clavicle fractures. J Am Acad Orthop Surg. 2019;27:405–9.
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. 2015;40:1106–9.
Tharao MK, Oroko P, Abdulkarim A, Saidi H. Validation of the Ottawa ankle rules at a tertiary teaching hospital. Ann Afr Surg. 2015;12:77–80.
Tufescu T. The cost of screening radiographs after stable fracture fixation. Can J Surg. 2017;60:53–6.
Vicente-Guijarro J, Valencia-Martin JL, Moreno-Nunez P, Ruiz-Lopez P, Mira-Solves JJ, Aranaz-Andres JM, et al. Estimation of the overuse of preoperative chest X-rays according to “Choosing Wisely”, “No Hacer”, and “Essencial” initiatives: are they equally applicable and comparable? Int J Environ Res Public Health. 2020;26;17(23):8783.
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;23:237–40.
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.
Wrotek A, Czajkowska M, Jackowska T. Chest radiography in children hospitalized with bronchiolitis. Adv Exp Med Biol. 2019;1222:55–62.
Wu Y, Rose MQ, Freeman ML, Richard-Lany NP, Spaulding AC, Booth SC, et al. Reducing chest radiography utilization in the medical intensive care unit. J Am Assoc Nurse Practition. 2020;32:390–9.
Behmanesh B, Keil F, Dubinski D, Won S-Y, 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.
Benayoun MD, Allen JW, Lovasik BP, Uriell ML, Sporfer RM, et al. Utility of computed tomographic imaging of the cervical spine in trauma evaluation of ground-level fall. J Trauma Acute Care Surg. 2016;81:339–44.
Hayatghaibi SE, Sammer MBK, Varghese V, Seghers VJ, Sher AC. Prospective cost implications with a clinical decision support system for pediatric emergency head computed tomography. Pediatric Radiol. 2021;51:2561–7.
Kothari S, Kalinowski M, Kobeszko M, Almouradi T. Computed tomography scan imaging in diagnosing acute uncomplicated pancreatitis: Usefulness vs cost. World J Gastroenterol. 2019;25:1080–7.
Martyak M, Collins J, Burgess J. Optimization of resource allocation after implementation of mild traumatic brain injury treatment protocol. Am Surgeon. 2018;84:1303–6.
Miller BJ, Carmody Soni EE, Reith JD, Gibbs CP, Scarborough MT. CT scans for pulmonary surveillance may be overused in lower-grade sarcoma. Iowa Orthop J. 2012;32:28–34.
Parma C, Carney D, Grim R, Bell T, Shoff K, Ahuja V. Unnecessary head computed tomography scans: A level 1 trauma teaching experience. Am Surgeon. 2014;80:664–8.
Quick JA, Bartels AN, Coughenour JP, Barnes SL. Trauma transfers and definitive imaging: patient benefit but at what cost? Am Surg. 2013;79:301–4.
Sharma AN, Tiourin E, Banyard DA, Sharma SN, Ng WKY. Clinical utility of postoperative computed tomography imaging in orbital floor fracture management. Ann Plast Surg. 2019;83:43–7.
Stewart CN, Wood L, Barta RJ. Validation of the “Wisconsin Criteria” for obtaining dedicated facial imaging and its financial impact at a level 1 trauma center. Craniomaxillofac Trauma Reconstr. 2020;13:4–8.
Westfall KM, Purcell LN, Charles AG. Computed tomography for acute appendicitis diagnosis and confirmation in men: trends and cost implications. Amer Surgeon. 2021;87:364–9.
Al Darrab R, Almaini R, Alqarni H, Alfraidi OB, Khan I, Melaibary B, et al. The role of ultrasonography in the management of undescended testes. A 6 year review. Curr Pediatric Res. 2021;25:408–12.
Chamberlain RC, Pelletier JH, Blanchard S, Hornik CP, Hill KD, Campbell MJ. Evaluating appropriate use of pediatric echocardiograms for chest pain in outpatient clinics. J Am Soc Echocardiogr. 2017;30:708–13.
Jawa NA, Rosenblum ND, Radhakrishnan S, Pearl RJ, Levin L, Matsuda-Abedini M. Reducing unnecessary imaging in children with multicystic dysplastic kidney or solitary kidney. Pediatrics [Internet]. 2021/07/08 ed. 2021;148. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85113439519&doi=10.1542%2fpeds.2020-035550&partnerID=40&md5=1847908e7126ee5f6d724c1044394e3fhttps://publications.aap.org/pediatrics/article-abstract/148/2/e2020035550/179750/Reducing-Unnecessary-Imaging-in-Children-With?redirectedFrom=fulltext. Accessed 20 Apr 2023
Maurer MH, Winkler A, Wichlas F, Powerski MJ, Elgeti F, Huppertz A, et al. [Costs and role of ultrasound follow-up of polytrauma patients after initial computed tomography]. Kosten und Stellenwert von Ultraschallverlaufskontrollen bei polytraumatisierten Patienten nach initialer Computertomografie. 2012;184:53–8.
Mouawad NJ, Go MR, Haurani MJ, Moseley M, Satiani B. Elimination of medically unnecessary duplex venous scanning based on an established algorithm can result in significant cost savings under Medicare for the institution and the taxpayer. J Vasc Surg Venous Lymphat Disord. 2015;3:107–12.
Mousa AY, Broce M, Gill G, Kali M, Yacoub M, Aburahma AF. Appropriate use of d-dimer testing can minimize over-utilization of venous duplex ultrasound in a contemporary high-volume hospital. Ann Vasc Surg. 2015;29:311–7.
Mousa AY, Broce M, De Wit D, Baskharoun M, Abu-Halimah S, Yacoub M, et al. Appropriate use of venous imaging and analysis of the d-dimer/clinical probability testing paradigm in the diagnosis and location of deep venous thrombosis. Ann Vasc Surg. 2018;50:21–9.
Thompson TM, Hasselman TE, Wang Y, Jantzen DW. Appropriateness and cost-effectiveness of echocardiograms ordered by pediatric cardiologists and primary care providers for syncope. Clin Pediatr (Phila). 2021;60:459–64.
Amin N, McIntyre L, Carter T, Xerogeanes J, Voigt J. Cost-effectiveness analysis of needle arthroscopy versus magnetic resonance imaging in the diagnosis and treatment of meniscal tears of the knee. Arthroscopy. 2019;35:554-562.e13.
Babbel D, Rayan G. Magnetic resonance imaging in evaluating workers’ compensation patients. J Hand Surg. 2012;37:811–5.
Castillo S, Joodi R, Williams LE, Pezeshk P, Chhabra A. Sacrum magnetic resonance imaging for low back and tail bone pain: A quality initiative to evaluate and improve imaging utility. World J Methodol. 2021;11:110–5.
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;28:2153–60.
Dookeran KA, Groh JM, Ritacco DG, Marcus LR, Wang Y, Khan JY. An assessment of prevalence and expenditure associated with discharge brain MRI in preterm infants. PLoS ONE. 2021;16: e0247857.
Flaherty S, Zepeda ED, Mortele K, Young GJ. Magnitude and financial implications of inappropriate diagnostic imaging for three common clinical conditions. Int J Qual Health Care. 2019;31:691–7.
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;29:1911–4.
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 Plan Manag. 2019;34:e1437–47.
Kavosi Z, Sadeghi A, Lotfi F, Salari H, Bayati M. The inappropriateness of brain MRI prescriptions: a study from Iran. Cost Effect Resour Alloc. 2021;19:14.
Khan MM, Pincher B, Pacheco R. Unnecessary magnetic resonance imaging of the knee: How much is it really costing the NHS? Ann Med Surg. 2021. https://doi.org/10.1016/j.amsu.2021.102736.
Klein MA. Reuse and reduce: abdominal CT, lumbar spine MRI, and a potential 1.2 to 3.4 billion dollars in cost savings. Abdom Radiol. 2017;42:2940–5.
Martin CT, Morcuende J, Buckwalter JA, Miller BJ. Prereferral MRI use in patients with musculoskeletal tumors is not excessive. Clin Orthop Relat Res. 2012;470:3240–5.
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;141:410–9.
Pozo-Rosich P, Layos-Romero A, Martin-Delgado J, Pascual J, Bailon C, Tentor A, et al. Low-value care practice in headache: a Spanish mixed methods research study. J Headache and Pain. 2020;21:74.
Sheridan GA, Bisseru A, Glynn AA. The utility of MRI scans for a painful knee in the elderly patient. Ir J Med Sci. 2021;190:363–6.
dos Santos MA, Santos MS, Tura BR, Félix R, Brito ASX, De Lorenzo A. Budget impact of applying appropriateness criteria for myocardial perfusion scintigraphy: The perspective of a developing country. J Nucl Cardiol. 2016;23:1160–5.
Krill A, Cubillos J, Gitlin J, Palmer LS. Abdominopelvic ultrasound: A cost-effective way to diagnose solitary kidney. J Urol. 2012;187:2201–4.
Baugh CW, Sun BC, Syncope Risk Stratification Study Group. Variation in diagnostic testing for older patients with syncope in the emergency department. Am J Emerg Med. 2019;37:810–6.
Bledsoe J, Liepert AE, Allen TL, Dong L, Hemingway J, Majercik S, et al. The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies. Am J Surg. 2017;214:198–200.
Boutis K, Von Keyserlingk C, Willan A, Narayanan UG, Brison R, Grootendorst P, et al. Cost consequence analysis of implementing the low risk ankle rule in emergency departments. Ann Emerg Med. 2015;66:455-463.e4.
Cheung D, Puertolas-Lopez M, Scott G, Langshaw A, Diaz Y, Sosa MA, et al. Decreasing overutilization of echocardiograms and abdominal imaging in the evaluation of children with fungemia. J Clin Outcomes Manag. 2019;26:270–6.
Cooper M, Newman NA, Ibrahim AM, Lam E, Herman JM, Singh VK, et al. Unnecessary tests and procedures in patients presenting with solid tumors of the pancreas. J Gastrointest Surg. 2013;17:1218–23.
Cristofaro M, Busi Rizzi E, Schininà V, Chiappetta D, Angeletti C, Bibbolino C. Appropriateness: Analysis of outpatient radiology requests. Radiologia Medica. 2012;117:322–32.
De Roo B, Hoste P, Stichelbaut N, Annemans L, Bacher K, Verstraete K. Belgian multicentre study on lumbar spine imaging: Radiation dose and cost analysis; Evaluation of compliance with recommendations for efficient use of medical imaging. Eur J Radiol. 2020;125:108864.
Falchook AD, Salloum RG, Hendrix LH, Chen RC. Use of bone scan during initial prostate cancer workup, downstream procedures, and associated medicare costs. Int J Radiat Oncol Biol Phys. 2014;89:243–8.
Fields J, Alturkistani T, Kumar N, Kanuri A, Salem DN, Munn S, et al. Prevalence and cost of imaging in inpatient falls: The rising cost of falling. ClinicoEcon Outcomes Res. 2015;7:281–6.
Frisse ME, Johnson KB, Nian H, Davison CL, Gadd CS, Unertl KM, et al. The financial impact of health information exchange on emergency department care. J Am Med Inform Assoc. 2012;19:328–33.
Gupta S, Taylor N, Selvakumar D, Harnett PR, Wilcken N, Lee CI. Retrospective imaging audit and cost analysis of medical oncology inpatients admitted to Westmead Hospital. Internal Med J. 2014;44:1235–9.
Hill AD, Catapano JS, Surina JB, Lu M, Althausen PL. Clinical and Economic Impact of Duplicated Radiographic Studies in Trauma Patients Transferred to a Regional Trauma Center. J Orthop Trauma. 2015;29:e214–8.
House SA, Hall M, Ralston SL, Marin JR, Coon ER, Schroeder AR, et al. Development and use of a calculator to measure pediatric low-value care delivered in US Children’s Hospitals. JAMA Network Open. 2021;4(12):e2135184.
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. Southern Med J. 2014;107:707–14.
Jung HY, Vest JR, Unruh MA, Kern LM, Kaushal R. Use of health information exchange and repeat imaging costs. J Am Coll Radiol. 2015;12:1364–70.
Kazemian E, Schaffer HM, Wozniak A, Leonetti JP. Economic impact of diagnostic imaging in the workup of uncomplicated Bell’s Palsy. J Neurol Surg Part B Skull Base. 2022;83(3):323–7.
Keidar E, Singh J, Santiago-Rivera OJ, Wilkerson B, Babu S. Utility and value of pre-operative CT and MRI for cochlear implantation in the elderly. Am J Otolaryngol Head Neck Med Surg. 2021;42:102853.
Kim L, Min M, Roos D, Nguyen L, Yeoh E. Are staging investigations being overused in patients with low and intermediate risk prostate cancer? J Med Imaging Radiat Oncol. 2015;59:77–81.
Kushwaha AC, Shin K, Kalambo M, Legha R, Gerlach KE, Kapoor MM, et al. Overutilization of health care resources for breast pain. Am J Roentgenol. 2018;211:217–23.
Mafi JN, Russell K, Bortz BA, Dachary M, Hazel WA, Fendrick AM. Low-cost, high-volume health services contribute the most to unnecessary health spending. Health Aff. 2017;36:1701–4.
Massa I, Balzi W, Altini M, Berte R, Bosco M, Cassinelli D, et al. The challenge of sustainability in healthcare systems: frequency and cost of diagnostic procedures in end-of-life cancer patients. Supportive Care Cancer. 2018;26:2201–8.
Massa I, Balzi W, Burattini C, Gentili N, Bucchi L, Nanni O, et al. The challenge of sustainability in healthcare systems: Frequency and cost of inappropriate patterns of breast cancer care (the E.Pic.A study). Breast. 2017;34:103–7.
McAlister FA, Lin M, Bakal J, Dean S. Frequency of low-value care in Alberta, Canada: a retrospective cohort study. BMJ Qual Saf. 2018;27:340–6.
McGowan SM, Ramski DE, Homcha B, Sokunbi G. Are CT scans overutilized in the workup of vertebral compression fractures? Clin Spine Surg. 2019;32:166–9.
Morgan T, Wu J, Ovchinikova L, Lindner R, Blogg S, Moorin R. A national intervention to reduce imaging for low back pain by general practitioners: a retrospective economic program evaluation using Medicare Benefits Schedule data. BMC Health Serv Res. 2019;19(1):983.
Mortimer D, French SD, McKenzie JE, O’Connor DA, Green SE. Economic evaluation of active implementation versus guideline dissemination for evidence-based care of acute low-back pain in a general practice setting. PLoS ONE. 2013;8: e75647.
Nayeri A, Prablek MA, Brinson PR, Weaver KD, Thompson RC, Chambless LB. Short-term postoperative surveillance imaging may be unnecessary in elderly patients with resected WHO Grade i meningiomas. J Clin Neurosci. 2016;26:101–4.
Pellet AC, Erten MZ, James TA. Value analysis of postoperative staging imaging for asymptomatic, early-stage breast cancer: Implications of clinical variation on utility and cost. Am J Surg. 2016;211:1084–8.
Pistolese CA, Ciarrapico AM, della Gatta F, Simonetti G. Inappropriateness of breast imaging: cost analysis. Radiol Med (Torino). 2013;118:984–94.
Prasad SM, Gu X, Lipsitz SR, Nguyen PL, Hu JC. Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer in the United States. Cancer. 2012;118:1260–7.
Redd C, Thomas C, Willis M, Amos M, Anderson J. Cost of Unnecessary Testing in the Evaluation of Pediatric Syncope. Pediatr Cardiol. 2017;38:1115–22.
Shah AA, Petrosyan M, Nizam W, Roberson J, Guzzetta P. Resource overutilization in the diagnosis of lymphedema praecox. J Pediatric Surg. 2020;55:1363–5.
Thavorn K, Wang Z, Fergusson D, van Katwyk S, Arnaout A, Clemons M. Cost implications of unwarranted imaging for distant metastasis in women with early-stage breast cancer in Ontario. Curr Oncol. 2016;23:S52–5.
Trofimova AV, Kishore D, Urquia L, Tewkesbury G, Duszak R, Levy MD, et al. Imaging Utilization in Children With Headaches: Current Status and Opportunities for Improvement. Journal of the American College of Radiology. 2020/05/07 ed. 2020;17:574–83.
Vilar-Palop J, Hern, ez-Aguado I, Pastor-Valero M, Vilar J, González-Alvarez I, et al. Appropriate use of medical imaging in two Spanish public hospitals: a cross-sectional analysis. BMJ Open. 2018;8(3):e019535.
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;22:3466–73.
Winn AN, Kelly M, Ciprut S, Walter D, Gold HT, Zeliadt SB, et al. The cost, survival, and quality-of-life implications of guideline-discordant imaging for prostate cancer. Cancer Rep (Hoboken, NJ). 2022;5: e1468.
Wintermark M, Rosenkrantz AB, Rezaii PG, Fredericks N, Cerdas LC, Burleson J, et al. Predicted Cost savings achieved by the radiology support, communication and alignment network from reducing medical imaging overutilization in the medicare population. J Am Coll Radiol. 2021;18:704–12.
Curtis LH, Greiner MA, Patel MR, Duncan PW, Schulman KA, Matchar DB. Geographic variation and trends in carotid imaging among Medicare beneficiaries, 2001 to 2006. Circu Cardiovasc Qual Outcomes. 2010;3:599–606.
Fonseca R, Otahal P, Wiggins N, Marwick TH. Growth and geographical variation in the use of cardiac imaging in Australia. Intern Med J. 2015;45:1115–27.
Franc BL, Copeland TP, Thombley R, Park M, Marafino B, Dean ML, et al. Geographic variation in postoperative imaging for low-risk breast cancer. J Natl Compr Canc Netw. 2018;16:829–37.
Gransjøen AM, Lysdahl KB, Hofmann BM. Geographical variations in the use of diagnostic imaging of musculoskeletal diseases in Norway. Acta Radiol. 2019;60:1153–8.
Kabongo JM, Nel S, Pitcher RD. Analysis of licensed South African diagnostic imaging equipment. Pan Afr Med J. 2015;22(57):57.
McWilliams JM, Dalton JB, Landrum MB, Frakt AB, Pizer SD, Keating NL. Geographic variation in cancer-related imaging: Veterans Affairs health care system versus Medicare. Ann Intern Med. 2014;161:794–802.
Ganguli I, Ying W, Shakley T, Colbert JA, Mulligan KL, Friedberg MW. Cascade services and spending following low-value imaging for uncomplicated low back pain among commercially insured adults. J Gen Intern Med. 2023;38:1102–5.
McAlister S, McGain F, Breth-Petersen M, Story D, Charlesworth K, Ison G, et al. The carbon footprint of hospital diagnostic imaging in Australia. Lancet Reg Health—Western Pac [Internet]. 2022 [cited 2024 Jan 23];24. Available from: https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(22)00074-8/fulltext.
Kjelle E, Andersen ER, Soril LJJ, Van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging—a systematic review of interventions and outcomes. BMC Health Serv Res. 2021;21:983.
Landon SN, Padikkala J, Horwitz LI. Identifying drivers of health care value: a scoping review of the literature. BMC Health Serv Res. 2022;22:845.
Hofmann B. Is there a technological imperative in health care? Int J Technol Assess Health Care. 2002;18:675–89.
Hofmann B. Biases and imperatives in handling medical technology. Health Policy Technol. 2019;8:377–85.
Pronovost PJ, Urwin JW, Beck E, Coran JJ, Sundaramoorthy A, Schario ME, et al. Making a dent in the trillion-dollar problem: toward zero defects. NEJM Catalyst [Internet]. 2021. https://doi.org/10.1056/CAT.19.1064.
Pandya A. Adding cost-effectiveness to define low-value care. JAMA. 2018;319:1977–8.
Acknowledgements
The authors would like to thank Maria Engås Halsne for access to results from the pilot searches made in Medline.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Funding/Support
Open access funding provided by NTNU Norwegian University of Science and Technology (incl St. Olavs Hospital - Trondheim University Hospital). This work was supported by grant 302503 from the Norwegian Research Council. The funder had no role in the design and conduct of the study.
Conflict of Interest
Kjelle: No conflict of interest. Brandsæter: No conflict of interest. Andersen: No conflict of interest. Hofmann: No conflict of interest.
Ethics Approval
Not applicable.
Consent to Participate
Not applicable.
Consent for Publication (from patients/participants)
Not applicable.
Availability of Data and Material
Data extracted from the included papers are available in Online Supplementary Material File 4.
Code Availability
Not applicable.
Authors' Contributions
Kjelle: Planning, searching, screening, full-text screening, snowballing, analysis, drafting, and revision of the manuscript. Brandsæter: Planning, screening, full-text screening, snowballing, analysis, and manuscript revision. Andersen: Planning, screening, full-text screening, snowballing, analysis, and manuscript revision. Hofmann: Planning, screening, full-text screening, snowballing, analysis, and manuscript revision.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.
About this article
Cite this article
Kjelle, E., Brandsæter, I.Ø., Andersen, E.R. et al. Cost of Low-Value Imaging Worldwide: A Systematic Review. Appl Health Econ Health Policy 22, 485–501 (2024). https://doi.org/10.1007/s40258-024-00876-2
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40258-024-00876-2