Justification for an imaging exam, and the radiation exposure that comes with it, is a fundamental principle behind every patient scan. And yet, by some estimates, anywhere between 20% to 50% of radiology exams are likely to be inappropriate and provide little to no clinical benefit.

Researchers from the European Society of Radiology discussed the challenges of justification in a paper.

Here are a few of them:

1. Patient expectations Patients may not understand the effects and risks of radiation. Many often put their desire for imaging to be performed over concerns of radiation exposure, except when it comes to children. Family doctors and medical specialists often find it hard to say no to exams requested out of fear that it will break the patient’s trust in them.

2. Allocating resources High equipment costs make imaging services expensive. Without enough funding, radiology practices are unable to meet increased demand for greater numbers and more complex imaging. Imaging should only be justified in cases where input is most efficient and effective, such as when exams incorporate evidence-based protocols and clinical pathways; are agreed upon by a multidisciplinary medical team; and facilitated by computerized decision support (CDS) systems.

3. Safety culture Safety culture in radiology should allow for staff to challenge a practice if it may not be in the best interest of the patient or them. Protocols for conflict review and resolution should also be developed. Safety, however, should not be an excuse for not abiding by responsibilities laid out in policies and guidelines such as the Euratom Basic Safety Standards Directive, which oversees regulatory requirements of radiation protection for most of Europe.

4. Healthcare pathways While justification is used to determine appropriate radiation exposure, it does not take completely into account how radiation is delivered in healthcare. Justification in diagnostic imaging is often part of a predefined healthcare pathway that includes an initial assessment and periodic follow-up imaging. An initial imaging procedure may be justified because further imaging is expected but justifying further imaging is treated separately. Until initial imaging occurs, further imaging cannot be justified, illustrating a disconnect. It may be better, the authors say, to justify a series of exposures as part of an expected care pathway and reassess justification for some or all of subsequent procedures as the patient’s condition develops and care is subsequently modified.

One solution could be imaging referral guidelines based on local clinical and radiological practice, which can help referring clinicians better understand and communicate to patients when imaging is necessary and when it is not. Integrating them into CDS systems also helps and has already reduced the total number of imaging exams, and increased appropriate imaging in the U.S. Education and training of radiologists and non-radiology practitioners further ensures better radiation safety, as do audits of CDS systems and inspections of clinical practices by regulatory bodies.

“While there is evidence of improvement in European countries, it is essential that complacency does not reverse this trend. Justification is central to the goal of ensuring patient safety and appropriate care while simultaneously achieving better use of imaging facilities, better use of radiologists’ and radiographers’ knowledge and skills within these facilities, and better integration of imaging into the wider provision of healthcare at local and national levels,” wrote the authors.

The findings were published in the European Society of Radiology's journal, Insights into Imaging.