Opinion

Opinion
• •
Overutilization of Radiological Examinations 1
Ferris M. Hall, M.D.

Overutilization of radiological studies has become a significant economic consideration

in this country. The reasons for unnecessary examinations include indirect financial benefit
to physicians, medicolegal considerations, inadequate history provided to the radiologist,
and simply inappropriate requests. In many radiological examinations, the indications are
controversial or unknown. Recent Professional Standards Review Organization legislation
will probably diminish overutilization of radiological studies, both directly through peer review
and indirectly by providing comparison statistical data to facilitate better assessment of the
value of individual examinations. The final common pathway of the radiological examination
is the radiologist, who has the right and the duty to refuse studies, particularly when they
involve risk to the patient.

INDEX TERMS: Economics, medical • Opinions. Radiology and radiologists

Radiology 120:443-448, August 1976

• •
Approximately 6 % of the total health care expenditure
in this country can be attributed to diagnostic radiology,
and the number of radiological examinations increases
approximately 8% each year (1). While these statistics
reflect the greater availability and capability of radiology,
they are also attributable at least in part to unjustified de-
mands (2-5). There are several reasons for this excessive
use of radiological studies.
Financial Benefit
Few physicians receive direct monetary benefit from
referring patients for radiological studies, with the occa-
sional exception of reimbursement for participation in
angiography, myelography, biopsy, or other special pro-
cedures. Radiologists themselves practice a form of
self-referral when they recommend additional radiological
examinations, and such suggestions are difficult to ignore
in view of the present medicolegal situation. The indirect
benefits to an individual or institution which accrue through
excessive use of radiological studies are more difficult to
assess.
Many emergency rooms attempt to expedite work by
having paramedical personnel screen patients and refer
them directly to the radiology department prior to seeing
a physician. Some overworked physicians use the radi-
ology department in lieu of a more detailed and time-
consuming history or physical examination. The x-ray
requisition, like the prescription blank, can too easily
substitute for a lengthy discourse with a patient. Radio-
logical examinations done in private offices are frequently
repeated when the patient is admitted to the hospital, be-
cause it is easier to reorder them than locate and review
the previous study. These subtle forms of radiological
overutilization increase the efficiency of the referring
physician but add disproportionately to the overall cost of
medical care. The radiologist is understandably reluctant
to bite the hand that feeds him; and even when he ques-
tions the appropriateness of an examination, he finds it
difficult to challenge the judgmentof the referring physician
on the basis of the history available to him.
Medicolegal
Physicians' decisions are increasingly dictated by legal
considerations, and defensive medical practice is en-
couraged by both insurance companies and hospital ad-
ministrators in an attempt to avoid potential litigation. The
objectivity and permanence of the radiograph lend dis-
proportionate weight to it in legal judgments. In cases of
trauma, both the doctor and the litigation-minded patient
may insist upon a radiological examination with the all too
familiar x-ray requisition history of "doubtful fracture" or
"alleged injury." Even when the limited value of an ex-
amination is demonstrated and publicized, as in the case
of post-traumatic skull radiographs (6-8), their number
does not decrease. The editor of one radiology journal
recently suggested that most such patients could be given
requests for skull radiographs to be done the following day
(9), reasoning that the majority of asymptomatic patients

From the Department of Radiology, Beth Israel Hospital, Boston, Mass. Accepted for publication in January 1976. sjh

443
444
would not return for the examination and the physician
would thereby have satisfied both his medical and legal
responsibilities.
Recent attention to the legal aspects of medical care
has focused on the large monetary awards to litigants and
the escalating costs of malpractice insurance. These
considerations represent the tip of the financial medico-
legal iceberg. It has been suggested that "approximately
30 % of (the) total x rays ordered are related to the physi-
cian's concern for the potential malpractice threats and
are not primarily designed to assist the patient" (10). More
recently, the American College of Radiology Efficacy Study
has shown that in emergency situations 11% of radio-
logical examinations were requested primarily for medi-
colegal purposes (11). The dollar cost of defensive medical
practice as it relates to radiology is staggering.
Inadequate History
Obtaining pertinent clinical data is a continuing problem
for the radiologist (12), as an inadequate history may cause
interpretive errors or lead to unnecessary or unsatisfactory
studies. For example, in excretory urography, prior
knowledge of the patient's azotemic state often facilitates
a satisfactory study through the use of larger quantities of
contrast material and tomography. This is also true of in-
travenous cholangiography and tests of liver function; in
addition, a rise or fall in the bilirubin level is often the de-
termining factor in the decision to perform intravenous
cholangiography in a patient with jaundice (13).
In a patient who has undergone gastrojejunostomy,
swallowed barium quickly empties into the proximal small
bowel and obscures the anastomosis, resulting in an un-
satisfactory examination; this may be averted by informing
the radiologist of previous gastric surgery. Adequate ex-
amination for esophageal varices is rarely a routine part
of the upper gastrointestinal examination unless specifi-
cally requested by the physician or suggested by the pa-
tient's history.
Most routine abdominal radiographs do not include the
diaphragm and are inadequate for evaluation of splenic
size or faint gallstones lying outside the central beam.
When the clinician is specifically interested in these organs
a pertinent history will result in proper upper abdominal
radiographs and perhaps obviate the need for a repeat
examination or oral cholecystography.
Patients in busy clinics or hospitals are frequently
scheduled for multiple radiological studies at the time of
initial. workup. If the pertinent diagnosis is confirmed, any
remaining studies should be cancelled.
Tomography may be employed unnecessarily when the
clinician has misinterpreted the plain films or does not
adequatelyappreciate the limitations of the procedure. Our
department has diminished these expensive and time-
consuming examinations by one-third by requiring the
referring doctor to consult with the radiologist prior to
scheduling the study. Pulmonary nodules are too often
tomographed concomitant with or even prior to efforts to
OPINION August 1976
locate previous chest radiographs which might obviate the
need for the examination. On the other hand, a good radi-
ologist shouldobtain pertinent additional radiographs which
are not specifically requested. Tomography of a peripheral
lung nodule should include separate views of the carina
and hilar areas and perhaps a barium swallow in a patient
with a suspected primary neoplasm. Additional whole-lung
tomograms are indicated in the case of a suspected met-
astatic nodule. In such cases a misleading or deficient
history can result in a well-intentioned but academic ex-
ercise on the part of the radiologist or, conversely, an in-
adequate examination. Another example is the "admis-
sion" or "preoperative" chest radiograph suggesting a
subtle ominous lesion: the radiologist may document the
lesion with further studies only to discover afterward that
the abnormality relates to the patient's already known
metastatic disease.
Inappropriate or Controversial Indications
Ureteral calculi cannot be definitively diagnosed or
excluded by plain abdominal radiography, and yet this
separate examination is performed initially in many pa-
tients with suspected ureteral colic. A suspicious density
overlying the course of the ureter may actually lie outside
it, while an obstructing ureteral calculus may go unrec-
ognized because of its relative nonopacity or overlying
bone. Diagnosis requires excretory urography, which in-
cludes a preliminary radiograph of the abdomen and may
be therapeutic as well as diagnostic because of the as-
sociated osmotic diuresis.
The mere presence of hypertension can no longer be
considered an adequate indication for further diagnostic
examinations such as excretory urography. McNeil et al.
have estimated that "the dollar cost of screening and
treating the total American renovascular hypertensive
population is of the order of 10 to 13 billion dollars" (14)
and indicatedthat' 'the identification and surgical treatment
of hypertensive renovascular disease resulted in an in-
cremental benefit in morbidity over blind antihypertensive
medical therapy only when the compliance with medical
treatment was about 50 per cent or less" (15).
Many gynecologists obtain excretory urograms and
barium enema studies preoperatively from all patients with
pelvic masses to evaluate pelvic kidneys, ureteral ob-
struction or deviation, or colonic invasion. The barium
enema studyand occasionally the excretory urogram could
probably be omitted in conditions such as dermoid cyst,
where the diagnosis is relatively clear and there is no
suspicion of malignancy. Ultrasound may further obviate
the need for some of these examinations. I doubt that
routine excretory urography can be justified as a base-line
study in the event of subsequent ureteral damage.
Supine and horizontal-beam films of the abdomen are
frequently considered inseparable, particularly in the
surgical subspecialties. Although the latter projection helps
to identify air-fluid levels in suspected cases of bowel
obstruction, when obstruction is not a clinical consideration
Vol. 120 OPINION
the upright or lateral decubitus abdominal view usually
offers no additional information and requires a dispro-
portionate amount of technician time, gonadal irradiation,
and cost. In adult patients with possible bowel perforation,
the upright radiograph can rarely give an adequate display
of both the pelvic area and the diaphragm. A small pneu-
moperitoneum is shown to better advantage on a routine
chest radiograph (16) which should be obtained whenever
acute abdominal disease is suspected. When a radiologist
is in attendance, the decision to obtain further views can
be made after studying the initial supine abdominal ra-
diograph.
An abdominal radiograph is often included in the ad-
mission workup for gastrointestinal bleeding, even though
it is exceedingly rare for such views to provide pertinent
new information as to the source of bleeding. Such a pa-
tient should and will have an abdominal radiograph as part
of later anqloqraphlc and/or barium studies. A patient's
subsequent health is unlikely to be influenced by the many
incidental findings seen on abdominal radiographs (17).
The indications for abdominal radiographs in suspected
acute appendicitis are poorly defined. Some surgeons
obtain such views routinely in the hope of discovering an
unsuspected etiology for symptoms such as regional en-
teritis or ureteral calculus; others never obtain abdominal
roentgenograms if the index of suspicion is high and sur-
gery is contemplated.
Serial radiological documentation of clinical recurrence
or healing of duodenal ulcer disease is fortunately be-
coming less common. Some clinicians question the need
even for an initial barium examination in young persons
with classic symptoms of peptic ulcer. In this country the
incidence of gastric carcinoma in such patients is ex-
ceedingly rare. The prescribed treatment and often even
the clinical diagnosis of most patients with peptic ulcer
symptoms is influenced little by barium or endoscopic
studies, whether they demonstrate a duodenal ulcer or
show no abnormality.
In many centers, an upper intestinal examination is
obtained prior to steroid or heparin therapy in patients with
a history of peptic ulcer disease. It is questionable whether
base-line barium studies in such patients are indicated.The
presence of duodenal deformity as evidence of old peptic
ulcer disease is almost never considered a contraindication
to drug treatment in patients without ulcer symptoms when
there are strong indications for steroids or anticoagulant
medication. A recent large retrospective analysis has failed
to show any association between steroid therapy and
peptic ulceration (18).
In order to expedite clinical evaluation, requests for
combined oral cholecystography and upper gastrointestinal
series are often made. One study of 935 such patients
showed that when symptoms were typical of one system
or the other, the second examination added no therapeu-
tically significant information (19). In cases of possible
cholelithiasis, the barium examination should be cancelled
if gallstones are seen on the initial study.
Barium swallows, oral cholecystograms, and radio-
445 Opinion
graphs of the cervical spine are obtained by many physi-
cians in patients with atypical chest pain. In a study of such
patients (20), hiatal hernia, gallbladder disease, and cer-
vical spine abnormalities "showed no consistent associ-
ation with coronary heart disease, nor did they appear to
contribute significantly to the genesis of prandial or noc-
turnal angina or to the syndrome of angina pectoris with
normal coronary arteriograms.' ,
An increased incidence of colonic carcinoma associ-
ated with inguinal hernia was widely reported in the mid
1960's by a single group of investigators (21-23), who
recommended routine sigmoidoscopy and barium enema
study prior to inguinal herniorraphy in all patients 55 or
older. This has become routine practice among some
physicians in spite of subsequent reports disputing these
findings (24, 25). A more reasonable approach would be
careful screening of the stool for occult blood (26, 27).
In most hospitals, all patients undergoing general an-
esthesia are required to have a preoperative chest radio-
graph. Hospitals and clinics generally require chest ra-
diographs on admission or at the time of the initial visit.
Recent reports have questioned the efficacy of these
studies (28-30). SageI et 81. (30) suggested that "chest
radiographs, obtained solely because of hospital admission
or scheduled surgery, are not warranted in patients under
20" and that the lateral projection "can be eliminated from
routine screening examinations in patients 20 to 39 years
of age." Such suggestions, practiced on a national scale,
would have a substantial financial impact.
Annual chest radiographs are routine for many
employees. Tuberculosis is no longer a valid indication for
such periodic examinations in this country. The ability of
chest radiographs to detect early pulmonary carcinoma
has been doubted in one large study of high-risk persons
(31), but others have questioned these results (32, 33). In
persons not at high risk for lung carcinoma, however, such
screening has dubious justification.
Patients hospitalized for pneumonia or congestive heart
failure frequently have serial chest radiographs using a
mobile unit to document clinical improvement. The number
of such studies too often reflects the intensiveness of the
patient's care rather than the necessity of the examination.
The general availability and improved quality of mobile-unit
chest radiographs may result in the underutilization within
the radiology department of chest radiographs which are
of better quality, less expensive, and include the lateral as
well as the frontal projection.
The placement of normally-functioning venous pressure
catheters is routinely checked on chest radiographs taken
with a mobile unit. Chest radiographsare regularly obtained
after thoracocentesis and are routinely obtained daily with
a mobile unit in many or most patients on mechanical
ventilation. In all of these instances, it appears more rea-
sonable to obtain radiographs when indicated by the clin-
ical condition of the patient rather than on the basis of
arbitrary rules or time schedules.
A cardiac series with fluoroscopy is not indicated in
every case of cardiomegaly or congestive heart failure.
446 OPINION
Far too frequently, these studies do not have specific
therapeutic indications.
In patients without localized symptoms, the diagnostic
yield from a metastatic bone survey is relatively small,
requiring approximately 50 % destruction of cancellous
bone before lytic areas become visible. The radionuclide
bone scan is a far more sensitive examination; it should
precede the radiographic skeletal survey in practically all
cases and totally replace it in most types of primary neo-
plasms (34). Except in remote areas where bone scans are
unavailable, roentgenograms in these patients should be
limited to symptomatic areas or those shown to be sus-
picious by the scan.
Even without the use of magnification and fine-detail
techniques, radiographic evaluation of patients with sus-
pected primary hyperparathyroidism should be limited to
anteroposterior views of the hands rather than a parathy-
roid bone survey. The incidence of radiologically detect-
able abnormalities in this disease has progressively di-
minished in the past quarter of a century, primarily because
of earlier diagnosis. In a recent large review of patients
with primary hyperparathyroidism (35), of whom 38 %
were asymptomatic, only 10% had osseous abnormalities,
and all of them were limited to subperiosteal phalangeal
bone reabsorption. Patients with chronic azotemia have
secondary hyperparathyroidism: bone surveys or radio-
graphs of the hand in these patients, while often positive,
should be obtained only for specific. clinical reasons.
In many patients with cerebrovascular accidents, skull
radiographs can be omitted: when the clinical picture is
classical, the yield from such examinations probably
equals that of matched controls. Hayes and Shopfner have
suggested that in infancy or childhood "convulsions alone
do not constitute a valid indication for skull roentgeno-
grams" (36). Bull and Zilkha (37) have emphasized the
limited usefulness of routine skull radiographs in the
evaluation of headache, neck pain, vertigo, Meniere's
disease, and adult-onset seizures without abnormal
physical signs and suggest that a single lateral view may
suffice for patient screening in all of these conditions.
The common practice of obtaining radiographs of the
lumbosacral spine to assess acute back pain is particularly
unfortunate because such symptoms often occur in young
persons who receive direct gonadal irradiation. A simple
three-view lumbosacral spine examination provides the
same female gonadal irradiation (238-715 mR) as would
a daily chest radiograph for six (38), sixteen (39), or 98
years (40)! Effective gonadal shielding, while reducing
these doses, is difficult in women and often not practiced.
Most persons with acute back pain have self-limited
muscle or ligamentous "strains." Even when radicular
symptoms are present, these patients should recover with
rest and physical therapy. Additional oblique, angled, or
stress views in the lumbosacral examination are based on
the assumptionthat subtle osseous changes are a common
cause of low back pain (41), but this view is not currently
held by most orthopedists. Patients with chronic or atypical
back symptoms should have spine radiographs, although,
August 1976
with the exception of ankylosing spondylitis and pediatric
patients, it is only the rare diagnosis of tumor or infection
that is likely to influence subsequent treatment. Two
studies have shown no correlation between acute and
chronic back symptoms and a multitude of radiological
findings: spina bifida occulta, spondylolysis, spondylo-
listhesis, old compression fractures, Schmorl's nodes,
degenerative osteophytes, transitional vertebrae, scoliosis,
and osteoporosis (42, 43).
The above remarks also apply to cervical spine radio-
graphs. Degenerative changes, with or without associated
narrowing of neural foramina, are common in patients over
40, but their visualization rarely influences initial conser-
vative therapy of neck pain. Again, radiologica.l evaluation
is best reserved for persons with chronic or atypical
symptoms or suspected fracture.
Post-traumatic radiographs of the coccyx not only de-
liver large amounts of gonadal irradiation but give poor
visualization of these thin bones. More importantly, there
is little the radiologist is likely to diagnose in this easily
palpable area, including an acute fracture, that will affect
subsequent treatment.
The radiological documentation of suspected rib frac-
tures following minor trauma is usually superfluous. Clin-
ically inapparent pneumothorax or hemothorax is unlikely,
rarely requires medical intervention, and, indeed, will
usually not be appreciated unless a concomitant upright
chest radiograph is taken. Treatment relates more to
symptoms than to the radiological visualization or non-
visualization of a fracture.
"Calcific" tendinitis or bursitis of the shoulder and Os-
good-Schlatter's disease of the knee are clinical diag-
noses. The treatment of classic shoulder tendinitis is not
influenced by normal radiographs, and soft-tissue calcifi-
cations are frequent incidental findings in patients with no
history of shoulder discomfort. In Osgood-Schlatter's
disease, soft-tissue swelling is more evident on physical
examination than on the radiograph, and irregularity of the
anterior tibial epiphysis is a subjective evaluation which
correlates poorly with symptoms.
A staggering number of ankle examinations, including
2 % of all radiological examinations at Beth Israel Hospital,
are performed for acute ankle sprains. R:adiological
evaluation has become routine in virtually all ankle sprains
in many areas of the 'country. The differentiation of liga-
mentous ankle injuries from significant malleolar fractures
can be made clinically in most instances, and it is ques-
tionable whether longer periods of immobilization are re-
quired following radiological demonstration of the small
avulsion-type fractures sometimes associated with liga-
mentous tears.
The exact place of cephalopelvimetry in obstetrics is
controversial, and its use by individual obstetricians varies
enormously. In one recent survey of 67,078 deliveries (44)
pelvimetry was performed in 4,599 patients (6.9 % ),
varying from 1.8% to 15.7% among the 16 participating
hospitals. A normal. pelvimetry in this study gave little
reassurance that a cesarean section would not be nee-
Vol. 120 OPINION
essary, and in those women with cephalopelvic dispro-
portion pelvimetry did not significantly shorten the duration
of labor compared to clinical judgment alone. Modern
obstetric practice should substantially reduce the need for
this examination (a) through the use of fetal monitoring and
other more direct measures of labor progression, (b) by
recognition that cephalopelvic disproportion is often rel-
ative and overcome by oxytocin administration, and (c) by
earlier, more liberal use of cesarean section (45). Recent
work suggests an increase in leukemia in some children
exposed to irradiation in utero during pelvimetry (46).
DISCUSSION
Total comprehensive medical insurance engenders a
corresponding total lack of concern on the part of both
patients and doctors for individual cost/benefit consider-
ations. Slightly less comprehensive forms of insurance
might significantly decrease unnecessary radiological
examinations.
Greater public awareness and increasing government
medical expenditure should result in legislative pressure
to alleviate the adverse financial effects of the present
medicolegal situation in this country. Perhaps some form
of no-fault medical malpractice insurance, similar to that
in the automobile industry, will result; such legislation could
be expected to reduce the number of unnecessary radio-
logical examinations obtained for defensive medical pur-
poses.
Better clinical understanding of the limitations of radi-
ology and improved communication between clinician and
radiologist will help reduce the number of unnecessary or
unsatisfactory examinations. From a practical standpoint,
much of this education must take place during a physi-
cian's training as a medical student or house officer: in the
past, academic "roundsmanship" has too frequently en-
couraged additional and often superfluous diagnostic ex-
aminations.
The economic and political pressures generated by peer
review, as mandated by the recent Professional Standards
Review Organization legislation (47), can be expected to
curtail unnecessary radiological studies. Perhaps equally
as important as peer review in reducing the number of
radiological examinations will be the collection of com-
parative statistical data under this new legislation. In its
efficacy study (11), the American College of Radiology is
currently collecting data from referring clinicians, both
before and after the radiological examination, in an attempt
to evaluate whether these examinations are properly uti-
lized. Only through this type of cost-benefit data will the
usefulness of some of the controversial examples pre-
sented in this article become known.
The final common pathway of the radiological exami-
nation is the radiologist. As with any other consultant, he
has the right and the duty to refuse studies which are not
clinically justified, particularly when they are potentially
harmful. Along with this right and duty comes a new re-
sponsibility.
447 Opinion
ACKNOWLEDGMENTS: I wish to express my thanks to Herbert L. Ab-
rams, M.D., and Ms. Sally Edwards for their help in the preparation of
this manuscript.
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448 OPINION
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Department of Radiology
Beth Israel Hospital
330 Brookline Ave.
Boston, Mass. 02215