ABSTRACT
Background and Aims
Due to the increasing use of imaging services, this study aimed to estimate the number of unnecessary imaging services, normal and abnormal imaging examinations, and their determinant factors.
Methods
This cross‐sectional study was conducted at a district hospital in East Azerbaijan, Iran. Retrospective data were collected from the electronic medical records of patients referred to the Imaging Department between March and August 2022, using the Hospital Information System (HIS). Descriptive statistics and χ 2 tests were performed, followed by hierarchical logistic regression with AOR, 95% CI, using SPSS‐24 for analysis.
Results
About 28% of imaging examinations with abnormal results and 21% of the examinations with normal results were unnecessary. The probability of ultrasound abnormal imaging results was 67% lower than computed tomography (CT) scan (CT‐scan) (adjusted odds ratio (AOR) = 0.33 (0.212–0.50); p < 0.001). One year increase of patient age is associated with a 1% lower likelihood of having normal imaging (AOR = 0.99 (0.98–0.99); p < 0/001). Women were 20% less likely than men to have abnormal imaging results (AOR = 0.80 (0.65–0.98); p = 0.035). The probability of necessary imaging decreases by 1% for 1 year increase in patient age (p = 0.017), on the other hand, the probability of unnecessary chest radiography was 5% higher than a brain CT‐scan imaging (AOR = 2.05 (1.19–3.51); p = 0.009).
Conclusions
Unnecessary imaging were more frequently performed on the older patients. Additionally, ultrasound was less likely than CT‐scans to show abnormal findings, while chest radiography was more frequently deemed unnecessary compared to brain CT‐scans. These insights highlight the need for age‐ and modality‐specific guidelines to reduce unnecessary imaging and improve diagnostic efficiency.
Keywords: computed tomography examination, medical imaging, radiography, ultrasonography, unnecessary imaging
Summary
The unnecessary use of radiography imaging services was greater than ultrasound and CT scans (around 33% vs. 19%).
Male persons and elderly individuals were more likely to have abnormal results in their medical imaging examinations compared to the female and younger adults.
The probability of necessary imaging decreases by increase in patient age.
the probability of unnecessary chest radiography was 5% higher than a brain CT‐scan imaging.
1. Introduction
The inception of medical imaging techniques in health systems in the last three decades has made an evolution in diagnostic examinations and therapeutic modalities for better patient care [1]. Radiological diagnoses help physicians in the early detection of diseases, and subsequently, prevent more invasive procedures that are unnecessary to treat patients. However, the rising cost of imaging technologies during the past two decades highlights the growing concern about the use of these technologies all over the world [2]. Over‐prescription and overuse of diagnostic imaging without a rational medical reason, which could be attributed to advances in imaging technologies and the development of defensive medicine, not only result in increased costs and low quality of health services but it has posed a potential risk to patients due to radiation hazards [3, 4].
Due to the high cost of imaging technologies and resource limitations, especially in Low‐ and Middle‐Income Countries (LMICs), purchasing and using these technologies have caused many challenges, including an excessive increase in healthcare costs [5, 6]. The unlimited entry of these technologies to market may lead to supplier‐induced demand from service providers and excessive and unnecessary use of these services [2, 7, 8].
Supplier‐induced demand is tailored to the assumption of asymmetric information between physicians and patients. The patients do not have adequate knowledge to assess the quality and quantity of the services they receive; they rarely know what medical services they need and how much. Therefore, physicians may benefit from this information asymmetry [9, 10]. Furthermore, provider payment mechanisms, such as Fee‐for‐Service, could provide financial motivation for supplier‐induced demands for radiography examiners [11, 12]. Patients may also influence demands for several reasons, including unreasonable requests, excessive trust in the doctor, willingness to use more free services, and lack of awareness [9]. Patients often ask physicians to prescribe radiography examinations and Computed Tomography (CT) scans, especially in cases of trauma or accidents [13].
Although over‐prescription or overuse of medical services has damages that presumably outweigh their advantages, it has become common in many settings [14]. Some studies have suggested that approximately one‐fourth to half of the advanced imaging techniques did not show any improvement in patient outcomes, and as a result, might have been considered unnecessary [15, 16, 17]. Nevertheless, these percentages should be interpreted cautiously. Evidence shows a growing increase in over‐prescription and overuse of health services, especially in the fields of diagnostic tests, without considerable improvements [18]. This is especially an important challenge for LMICs, where they face great resource limitations [19, 20].
The study by Silva and colleagues in Brazil showed that CT scanner adoption in LMICs is largely driven by hospital administrators, physicians, and sales representatives, with little regulation by policymakers [21]. Extensive awareness of the issues connected with the use of medical imaging techniques can contribute to better planning and consequently appropriate uses in short‐time. In addition, lessons learned from an LMIC not only could be applied by professionals and decision‐makers in other LMICs with potential similar challenges but also could be useful for manufacturers and technologists to plan for the preparation of technologies that are more suitable for the contexts of LMICs countries. In this case study, we aimed to explore the situation of the use and prescription of medical imaging services in a district hospital in Iran.
2. Methods
2.1. Study Type and Population
This cross‐sectional study was conducted in a district hospital in the East Azerbaijan province of Iran. Retrospective data were collected from March to August 2022. The target population of the study were patients admitted to the Imaging Department of the hospital.
2.2. Study Setting
Baqer‐al‐Olum Hospital, located in Ahar, East Azerbaijan Province, Iran, is a general hospital providing a wide range of healthcare services. These include emergency care, surgical procedures, internal medicine, obstetrics and gynecology, medical imaging, and various other specialized departments. As a key healthcare facility in the region, Baqer‐al‐Olum Hospital serves not only the residents of Ahar but also individuals from surrounding rural areas. The hospital is equipped with modern diagnostic tools, including radiology, ultrasound, and CT scan equipment, supporting the accurate diagnosis and treatment of patients. It is a vital healthcare provider in the region, addressing a broad spectrum of medical needs.
2.3. Data Source
All data in this study were collected from the Hospital Information System (HIS). We collected data from patients' electronic medical records that are routinely recorded in HIS. We pulled out all relevant data into a data extraction Excel form. The form contained three main parts including patients' information, physicians' information, and information on imaging services. Patient information encompassed demographic information such as age, sex, health insurance status, and information on inpatient or outpatient services. Physicians' information included demographic information such as age, sex, and education. Information on imaging services included the types of imaging examinations such as CT scans, radiography, and ultrasound, the types of requested imaging examinations including CT scans of the brain, CT scans of facial veins, chest radiography, and abdominal and pelvic ultrasounds, the cause of hospitalization, final diagnostic decision, and the final results of imaging (normal or abnormal). Diagnosis of normal or abnormal imaging results was based on the diagnosis recorded in the HIS by the physician.
2.4. Eligibility Criteria
All patients referred to the imaging department of Baqer Al‐Uloom Hospital for imaging services regardless of their age, sex, health status, and other demographic information were included in the study. Referral of fewer than 10 cases of any type of imaging services during the study period by a physician was considered as exclusion criteria to ensure a robust sample size and meaningful analysis. This threshold helps to avoid potential biases and inaccuracies that could arise from analyzing data with insufficient cases.
2.5. Unnecessary Medical Imaging
According to Rao et al. [13], imaging procedures such as routine chest radiography in patients without cardiopulmonary symptoms, imaging for headaches in patients without risk factors, and CT for suspected appendicitis in children were considered unnecessary. In the present study, we considered 100% unnecessary examinations to include:
Routine chest radiography in patients without cardiopulmonary symptoms,
Imaging for a headache in patients without symptoms of the risk factors (e.g., CT scan of the brain),
CT scan of facial veins in simple rhinosinusitis.
All other imaging procedures were considered necessary if they did not meet these criteria for unnecessary classification.
The records were reviewed by a team of medical records experts and health information technology experts, using a checklist developed from the criteria outlined in the study by Rao and colleagues [13]. Any imaging examination lacking the necessary clinical signs or symptoms was flagged as unnecessary based on the information recorded in the HIS and according to the checklist. The ratio of unnecessary imaging tests to total tests performed was calculated to determine the rate of unnecessary imaging.
2.6. Data Analyses
We reported descriptive statistics (frequency and percentage) for the number of necessary/unnecessary or normal/abnormal cases. The χ 2 test was used to determine differences in distribution between different types of imaging examinations. We used hierarchical logistic regression analysis in two steps using the Enter method. Characteristics of physicians and patients found to be associated with normal/abnormal and necessary/unnecessary imaging results in the univariate analysis were included in multiple logistic regression models. The p values for entry and removal variables in the stepwise logistic regression model were 0.05 and 0.15, respectively. For logistic regression analysis, we used an adjusted odds ratio (AOR) and 95% confidence intervals (95% CI). Hosmer and Lemeshow test was conducted to examine the Goodness of Fit of the final model. The significance level of the tests was considered to be 0.05 (two‐tailed). Data were analyzed using SPSS‐24 software.
3. Results
Medical records of 2090 radiology department patients were examined. Around 60.5% of patients were female and the mean age was 42 years. Most of the imaging examinations were requested by specialists (67%), and among three prescribed imaging examinations, including CT‐scan, radiography, and sonography, sonography was the most frequently used one (62%) (Table 1).
Table 1.
Characteristics of patients who underwent medical imaging examinations in a district hospital in the north‐west of Iran.
| Variable | Mean (SD) | Variable | No (%) |
|---|---|---|---|
| Patient age | 41.87 (24.21) years | Physician specialty | |
| Physician age | 44.92 (9.04) years | General practitioner | 692 (33) |
| Variable | No (%) | Obstetricians | 210 (10) |
| Patient sex | Pediatrician | 188 (9) | |
| Male | 825 (39.5) | Surgeon | 112 (5.5) |
| Female | 1265 (60.5) | Internist | 888 (42.5) |
| Condition | |||
| Inpatient | 715 (34) | Insurance type | |
| Outpatient | 1375 (66) | Social security | 505 (24.2) |
| Physician sex | Health service | 135 (6.5) | |
| Male | 1351 (64.5) | Armed forces | 61 (2.9) |
| Female | 739 (35.5) | Rural | 535 (25.6) |
| Physician education | Public health | 422 (20.2) | |
| General practitioner | 688 (3) | Iranians | 21 (1) |
| Specialist | 1402 (67) | Traffic accident | 97 (4.6) |
| Imaging services | Aid committee | 78 (3.7) | |
| CT‐scan | 221 (10.5) | Private | 212 (10.1) |
| Radiography | 569 (27.5) | Other strata | 24 (1.1) |
| Sonography | 1300 (62) |
3.1. Normal and Abnormal Results
The results showed that most imaging examinations with abnormal results were CT‐scan (86%), ultrasound (72.5%), and radiography (50.4%) (Table 2).
Table 2.
Normal/abnormal imaging results in a district hospital in the north‐west of Iran.
| Imaging services | Imaging examinations with abnormal results | Imaging examinations with normal results | p value | ||
|---|---|---|---|---|---|
| Number | Percentage (%) | Number | Percentage (%) | ||
| CT‐scan | 190 | 86 | 31 | 14 | < 0.001* |
| Radiography | 287 | 50.4 | 282 | 49.6 | |
| Ultrasound | 942 | 72.5 | 358 | 27.5 | |
The χ 2 test.
The Examination results of 908 women (71.8%), 511 men (61.9%), 528 inpatient cases (73.8%), and 891 outpatient cases (64.8%) were abnormal. Additionally, abnormal results were observed in 903 male physicians (66.8%) and 516 female physicians (69.8%) prescriptions. Also, 510 general practitioners (74.1%) and 909 specialists (64.8%) had abnormal results. Specifically, abnormal results were noted in 512 general practitioners (74%), 173 gynecologists (82.4%), 74 pediatricians (39.4%), 53 surgeons (47.3%), and 607 internal medicine specialists (68.4%) prescriptions.
According to the results of multiple logistic regression, after adjusting for the variables of imaging services, patient sex, condition, physician age, physician education, physicians' work experience, and physician specialty, 1 year increase of patient age was associated with a 1% lower likelihood of having abnormal imaging (AOR = 0.99 (0.98–0.99); p < 0.001) (Table 3). Women were 20% less likely than men to have abnormal imaging results. (AOR = 0.80 (0.65–0.98); p = 0.035) (Table 3). The likelihood of normal results in radiography is 80% (AOR = 0.20 (0.130.31), p < 0.001), and in sonography it is 67% (AOR = 0.33 (0.21–0.50), p < 0.001) less than CT‐scans. In addition, obstetricians were 4.65 times and internists were 1.68 times and surgeons were 0.22 times more likely than general practitioners to report abnormal imaging results (Table 3).
Table 3.
Univariate and multiple logistic regression analysis of normal/abnormal imaging results in a district hospital in the north‐west of Iran.
| Variable | No | Normal frequency (%) | Unadjusted | Adjusted** | |||
|---|---|---|---|---|---|---|---|
| OR (95% CI) | Wald | p value | OR (95% CI) | p value | |||
| Patient age | 2082 | 1419 (68.1) | 1.0 (0.99–1.01) | 2.89 | 0.089 | 0.99 (0.98–0.99) | < 0.001 |
| Patient sex | 22.04 | < 0.001 | |||||
| Male* | 825 | 511 (61.9) | 1 | 1 | |||
| Female | 1265 | 908 (71.8) | 0.64 (0.53–077) | 0.80 (0.65–0.98) | 0.035 | ||
| Condition | 17.54 | < 0.001 | |||||
| Inpatient* | 1715 | 528 (73.8) | 1 | 1 | |||
| Outpatient | 1375 | 891 (64.8) | 1.53 (1.251–87) | 1.01 (0.79–1.29) | 0.920 | ||
| Physician age | 2090 | 1419 (68.1) | 0.99 (0.98–0.99) | 6.39 | 0.011 | 1.02 (0.99–1.04) | 0.295 |
| Physician sex | 1.95 | 0.162 | |||||
| Male* | 1351 | 903 (66.8) | 1 | 1 | |||
| Female | 739 | 516 (69.8) | 0.87 (0.72–1.06) | 0.76 (0.58–0.98) | 0.033 | ||
| Physician education | 18.14 | < 0.001 | |||||
| General practitioner* | 688 | 510 (74.1) | 1 | 1 | 0.257 | ||
| Specialist | 1402 | 909 (64.8) | 0.64 (0.53–0.79) | 0.31 (0.04–2.33) | |||
| Physician specialty | |||||||
| General practitioner* | 692 | 512 (74) | 1 | 1 | |||
| Obstetricians | 326 | 262 (80.4) | 1.44 (1.04–1.99) | 4.92 | 0.027 | 5.65 (0.76–42.00) | 0.091 |
| Pediatrician | 188 | 74 (39.4) | 0.23 (0.16–0.32) | 73.27 | < 0.001 | 0.73 (0.09–5.57) | 0.758 |
| Surgeon | 71 | 35 (49.3) | 0.34 (0.21–0.56) | 18.05 | < 0.001 | 1.22 (0.15–9.69) | 0.850 |
| Internist | 813 | 536 (67.9) | 0.68 (0.54–0.85) | 11.43 | 0.001 | 2.68 (0.37–19.56) | 0.331 |
| Physician work experience | 2090 | 1419 (68.1) | 1.01 (1–1.03) | 10.59 | < 0.001 | 0.97 (0.93–0.99) | 0.027 |
| Imaging services | |||||||
| CT‐scan* | 221 | 190 (86) | 1 | 1 | |||
| Radiography | 569 | 287 (50.4) | 0.17 (0.11–0.25) | 72.3 | < 0.001 | 0.20 (0.13–0.31) | < 0.001 |
| Sonography | 1300 | 942 (72.5) | 0.43 (0.29–0.64) | 17.28 | < 0.001 | 0.33 (0.212–0.50) | < 0.001 |
| Insurance | |||||||
| Social security* | 505 | 348 (68.9) | 1 | — | — | ||
| Health service | 135 | 91 (67.4) | 1.07 (0.71–1.60) | 0.112 | 0.739 | — | — |
| Armed forces | 61 | 46 (75.5) | 1.33 (0.39–0.72) | 1.07 | 0.299 | — | — |
| Rural | 535 | 345 (64.5) | 1.22 (0.94–1.58) | 2.28 | 0.131 | — | — |
| Public health | 422 | 289 (68.5) | 1.02 (0.77–1.34) | 0.02 | 0.889 | — | — |
| Iranians | 21 | 11 (52.4) | 2.01 (0.83–4.84) | 2.45 | 0.117 | — | — |
| Traffic accident | 97 | 80 (82.5) | 0.47 (0.27–0.82) | 7.03 | 0.008 | — | — |
| Aid committee | 78 | 42 (53.8) | 1.90 (1.17–3.08) | 6.77 | 0.009 | — | — |
| Private | 212 | 151 (71.2) | 0.89 (0.63–1.27) | 0.37 | 0.539 | — | — |
| Other strata | 24 | 16 (65.5) | 1.18 (0.49–2.84) | 0.13 | 0.729 | — | — |
Note: Dependent variable: Nomality of imaging/ * = Reference category/ ** = Goodness of Fit; Hosmer and Lemeshow Test; (F Change (8, 2090) = 5.108, p = 0.746).
Abbreviations: CI, confidence interval; OR, odds ratio.
3.2. Unnecessary Examinations
The results showed that 19% of CT scans and 32.9% of radiographic tests performed during the study period were unnecessary (Table 4). According to the results, 125 out of 419 male patients (29.8%) and 104 out of 371 female patients (28%) had unnecessary imaging examinations. Moreover, out of 104 hospitalized patients, 33 (31.7%) and 196 out of 686 outpatient cases (28.5%) had unnecessary imaging examinations. Additionally, 15% of medical images prescribed by general practitioners, and 32% of those prescribed by all types of specialists (12.5% of obstetricians, 50.4% of pediatricians, 24.1% of surgeons, and 28.1% of internists) were unnecessary. In terms of the types of examinations, 17.6% of brain CT scans, 40% of chest radiographs, and 44.4% of facial vein CT scans were unnecessary. In addition, 27.7% of imaging examinations with abnormal results and 21% of the examinations with normal results were unnecessary (Table 5).
Table 4.
Necessary/unnecessary imaging examinations in a district hospital in the north‐west of Iran.
| Imaging services | Necessary | Unnecessary | p value | ||
|---|---|---|---|---|---|
| Number | Percentage (%) | Number | Percentage (%) | ||
| CT‐scan | 179 | 81 | 42 | 19 | < 0.001* |
| Radiography | 382 | 67.1 | 187 | 32.9 | |
The χ 2 test.
Table 5.
Univariate and multiple logistic regression of necessity of imaging results in a district hospital in the north‐west of Iran.
| Variable | No | Necessity proportion | Unadjusted | Adjusted** | |||
|---|---|---|---|---|---|---|---|
| OR (95% CI) | Wald | p value | OR (95% CI) | p value | |||
| Imaging results | |||||||
| Non‐normal* | 477 | 345 (72.3) | 1 | 1.01 | 0.315 | 1 | |
| Normal | 313 | 216 (69) | 1.17 (0.85–1.60) | 0.95 (0.66–1.37) | 0.787 | ||
| Patient age | 785 | — | 0.99 (0.98–0.99) | 10.19 | 0.001 | 0.99 (0.99–0.99) | 0.017 |
| Patient sex | 0.310 | 0.578 | |||||
| Male* | 419 | 294 (70.2) | 1 | ||||
| Female | 371 | 267 (72) | 0.91 (0.67–1.2) | ||||
| Condition | 17.54 | 0.508 | |||||
| Inpatient* | 104 | 71 (68.3) | 1 | ||||
| Outpatient | 686 | 490 (71.4) | 0.86 (0.55–1.34) | ||||
| Physician age | 790 | — | 1.02 (1–1.04) | 4.25 | 0.039 | 0.99 (0.96–1.04) | 0.922 |
| Physician sex | 0.786 | 0.375 | |||||
| Male* | 593 | 426 (71.8) | 1 | ||||
| Female | 197 | 135 (68.5) | 1.17 (0.82–1.66) | ||||
| Physician education | 15.59 | < 0/001 | |||||
| General practitioner* | 141 | 120 (85.1) | 1 | 0.017 | |||
| Specialist | 649 | 441 (68) | 2.69 (1.64–4.40) | 2.15 (1.15–4.03) | |||
| Physician specialty | |||||||
| General practitioner* | 141 | 120 (85.1) | 1 | ||||
| Obstetricians | 8 | 7 (87.5) | 0.81 (0.09–6.98) | 0.034 | 0.853 | ||
| Pediatrician | 137 | 68 (49.6) | 5.79 (3.27–6.14) | 36.27 | < 0/001 | ||
| Surgeon | 87 | 66 (75.9) | 1.81 (0.92–3.57) | 3.01 | 0.083 | ||
| Internist | 417 | 300 (71.9) | 1.81 (0.92–3.57) | 9.46 | 0.002 | ||
| Physician work experience | 790 | — | 1.02 (1–1.04) | 6.81 | 0.009 | 1.03 (0.99–1.07) | 0.182 |
| Imaging services | |||||||
| Brain CT‐scan* | 170 | 140 (82.4) | 1 | 14.47 | 1 | — | |
| Chest radiography | 467 | 270 (60) | 3.11 (2.01–4.81) | 26.16 | < 0/001 | 2.05 (1.19–3.51) | 0.009 |
| Facial veins CT‐scan | 27 | 15 (55.6) | 3.73 (1.58–8.78) | 9.11 | 0.003 | 2.13 (0.84–5.45) | 0.113 |
| Insurance | 1.18 | 0.227 | |||||
| Social security* | 202 | 140 (69.3) | 1 | ||||
| Health service | 56 | 43 (76.8) | 0.68 (0.34–1.35) | ||||
| Armed forces | 26 | 13 (50) | 2.25 (0.99–5.15) | 3.74 | 0.053 | ||
| Rural | 221 | 153 (69.2) | 1 (0.66–1.51) | < 0/001 | 0.986 | ||
| Public health | 121 | 79 (65.3) | 1. 2 (0.74–1.93) | 0.559 | 0.455 | ||
| Iranians | 11 | 6 (54.5) | 1.88 (0.55–6.39) | 1.02 | 0.311 | ||
| Traffic accident | 50 | 48 (96) | 0.09 (0.02–0.39) | 10.26 | 0.001 | ||
| Aid committee | 37 | 27 (73) | 0.83 (0.38–1.83) | 0.199 | 0.655 | ||
| Private | 54 | 42 (77.8) | 0.46 (0.31–1.30) | 0.064 | 0.225 | ||
| Other strata | 15 | 10 (83.3) | 0.45 (0.09–2.12) | 0.45 | 0.314 | ||
Note: Dependent variable: Necessity of imaging/ * = Reference category/ ** = Goodness of Fit; Hosmer and Lemeshow Test; (F Change (8, 659) = 11.25, p = 0.188).
Abbreviations: CI, confidence interval; OR, odds ratio.
The results of logistic regression showed that the probability of necessary imaging decreases by 1% for every year increase in age of a patient (p = 0.017).
4. Discussion
We analyzed the data on the patients who underwent medical imaging examinations in a district hospital to find the area of the high utilization of the examinations by estimating the number of necessary/unnecessary examinations and normal/abnormal imaging results and factors attributed to unnecessary examinations. The results showed that among all the examinations, the excessive use of radiography imaging services was greater than ultrasound and CT scans showing that around 33% of radiographic and 19% of CT scans were unnecessary.
This study revealed that among the evaluated imaging techniques, the most essential were CT scans of the brain, followed by chest radiography, and then CT scans of facial veins. Compared to our results, a study by Lee and colleagues showed that CT scans of the abdomen, brain, and chest were the most repetitive and the most requested examinations [22]. Our results also showed that approximately 19% of CT scans and 33% of radiographic were found to be unnecessary. A study of diagnostic and imaging services in California by Mitchell found that CT services increased by 50% between 2000 and 2004 [23]. Ramswarth et al. also showed that Out of 470 CT examination forms, 195 (41.49%) were classified as inadequate requests [24]. Although financial incentive has been known to contribute to increased utilization of medical imaging services, it is not the only motivating factor. The ordering of inappropriate CT examinations is influenced by a range of both clinical and nonclinical factors [25, 26] misjudgment, lack of awareness of alternative imaging modalities, noncompliance with clinical guidelines, lack of awareness regarding the risks associated with imaging and inadequate communication between healthcare professionals [27, 28, 29]. Reducing these instances requires the implementation and promotion of evidence‐based guidelines, continuous education for providers and patients regarding the risks and appropriate utilization of imaging, and fostering clear communication pathways between referring physicians and radiologists to ensure that imaging is conducted only when necessary [25, 28, 29, 30].
We also found a direct association between patients' and physicians' age and the likelihood of necessary imaging. The older the patients/physicians were, the more likely they were to report necessary examinations. However, we couldn't find a statistically significant association between patient/physician sex and the likelihood of performing necessary imaging. We also observed statistically notably positive associations between physicians' year‐of‐work experience and probability of necessary tests, which is not surprising when considering the skills, they might have gained in their profession. Work experience could also be a reason for the association between necessary examinations and physicians' age. Unnecessary examinations could be attributed to a range of factors from technical issues to maturity in professional practice. For example, a study, examining the causes of unnecessary repeated medical imaging examinations in Australia, showed that around 70%–80% of errors in radiographic tests were performed by junior radiographers. Moreover, students were involved in approximately 60%–85% of the repeated cases by senior radiographic tests [31]. A survey study by Lysdahl and colleagues in Norway attributed the causes of increasing use of radiological examinations to customer demands, clinicians' uncertainty about patients' condition, extended clinical indications, and availability of the examinations. The reasons for increasing unnecessary investigations, on the other hand, were cited as “over‐investigation” and “insufficient referral information” [32].
We found that the older patients were more likely than younger patients, and male patients were more likely than female patients to have abnormal imaging results. Among all professions, internists were least likely and pediatricians were most likely to report abnormal imaging results than general practitioners. Approximately 28% of imaging examinations with abnormal results were found to be unnecessary which brings insight into how indications and criteria for deciding on conducting an imaging examination can affect the diagnosis results. Moreover, 31% of the examinations with normal results were found to be unnecessary. This might be because of cultural issues, unnecessary referrals, or intolerance of the physicians for uncertainty [31, 32, 33].
5. Implications
It seems that if accurate clinical examinations of patients are performed more carefully, unnecessary cases can be reduced considerably. Due to the high costs that unnecessary examinations can pose to health systems, it is indispensable to adopt measures to control the unnecessary examinations and imaging services as much as possible. Financial incentives for physicians and educational courses for improving the physicians' skills, for example, can be beneficial. Moreover, the development and adaptation of national clinical practice guidelines to guide physicians in the prescription of imaging services can help them legally avoid unnecessary defensive medicine strategies.
5.1. Limitations
We acknowledge that this study has some limitations. The study was conducted in a single district hospital that can restrict the generalizability of the results to the whole country. However, we included all data from the hospital in the study and the hospital serves the whole population of the district and territories. As a result, this study has extreme generalizability to other district areas in the whole country. Moreover, by including all patients with medical imaging examinations in the study, the results provide essential information on the factors that can determine the probability of the necessity of the examinations or abnormality of the results even in other countries. Regardless of the limitations, this study provides a holistic view of the factors that can contribute to unnecessary imaging services and strategies that would improve the imaging prescriptions. Hence much improvement could be seen in the quality of imaging prescriptions and imaging services provided for patients in need.
6. Conclusion
The results showed CT scans, ultrasound, and radiography had the highest abnormal imaging results. Considering the growing increase in the utilization of imaging services and a high proportion of unnecessary medical imaging examinations, particularly of those with normal results, appropriate strategies must be adapted to prevent the increasing costs of these services which have a high burden on both patients and insurance organizations. This necessitates professionals and policymakers to identify and control the factors influencing the inappropriate use of these services. In this study, we identified some fundamental factors attributed to the implementation of necessary or unnecessary examinations as well as those with normal or abnormal clinical results.
Author Contributions
Supervision: Kamal Gholipour, Ramin Rezapour, and Shabnam Iezadi. Conceptualization: Kamal Gholipour, Ramin Rezapour, and Shabnam Iezadi. writing original draft: Kamal Gholipour, Ramin Rezapour, and Shabnam Iezadi. Data analysis and interpretation: Kamal Gholipour and Akbar Ghiasi. Data curation and editing original draft: Solmaz Azimzadeh and Fariba Badrzadeh.
Ethics Statement
The study was approved by the Research & Ethics Committee of Tabriz University of Medical Sciences (number: IR.TBZMED.REC.1398.023). All methods were carried out in accordance with relevant guidelines and regulations in Iran. All authors have read and approved the final version of the manuscript. [Ramin Rezapour] have full access to all of the data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The lead author Ramin Rezapour affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Acknowledgments
We are deeply grateful of the contribution of Baqer Al‐Uloom Hospital managers and employees on data collection.
Kamal Gholipour and Shabnam Iezadi contributed equally to this work.
Data Availability Statement
The data used in this article were obtained with the permission of Tabriz University of Medical Sciences. In case of request, the data can be accessed by the corresponding author: rrezapour313@gmail.com after obtaining permission to republish the data from Tabriz University of Medical Sciences.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used in this article were obtained with the permission of Tabriz University of Medical Sciences. In case of request, the data can be accessed by the corresponding author: rrezapour313@gmail.com after obtaining permission to republish the data from Tabriz University of Medical Sciences.