key: cord-0030176-ilzq9xb4 authors: Kjelle, Elin; Andersen, Eivind Richter; Krokeide, Arne Magnus; Soril, Lesley J. J.; van Bodegom-Vos, Leti; Clement, Fiona M.; Hofmann, Bjørn Morten title: Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review date: 2022-04-21 journal: BMC Med Imaging DOI: 10.1186/s12880-022-00798-2 sha: 0f0924b9e0a861618d15504e04c99b543e9a9323 doc_id: 30176 cord_uid: ilzq9xb4 BACKGROUND: Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS: A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS: A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS: A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. Systematic review registration: PROSPERO: CRD42020208072. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12880-022-00798-2. The use of health care and health care expenditures are increasing in most countries [1] . According to the Organization for Economic Co-operation and Development (OECD) 10-34% of health service spending is inappropriate and wasteful use of health care resources [2] . Diagnostic imaging is a health care resource aiding the physician in identifying correct diagnoses and administering the right treatment for the right patient at the right time [3] . However, imaging services can also be inappropriately used or be of low clinical value. While inappropriate imaging is characterized by not being in accordance with professional norms and guidelines, low-value care is defined as services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary cost to patients, or waste limited healthcare resources. Diagnostic imaging would be of low-value when the examination has little or no impact on the management of the individual patient, thus in a societal perspective increasing costs and constituting an unnecessary risk to patients due to exposure to ionizing radiation [4] and/or contrast media [5] . Earlier research found that 20-50% of radiological examinations are overused, however, this rate varies between and within countries [2, [6] [7] [8] . Recommendations and guidelines such as the National Institute for Health and Care Excellence's (NICE's) "Do-not-do list, " iRefer, iGuide and the international Choosing Wisely campaign have been introduced to reduce overutilization in health care and reduce low-value care, including diagnostic imaging [9] [10] [11] . So far, the impact of such efforts is reportedly low, as patient expectations of advanced diagnostic tests, lack of knowledge among health care professionals on the right use of imaging, established clinical practice, fear of malpractice, and fee-for-service reimbursement systems continue to drive the use of low-value care [6, [12] [13] [14] [15] [16] . Knowledge about low-value imaging in terms of characteristics, quantities and contexts is warranted to enable adequate prioritizing of resource utilization and designing de-implementation initiatives. A recent systematic review previously estimated the prevalence of low-value diagnostic testing, which included some radiological services, but did not provide a complete overview of which diagnostic imaging examinations that may be regarded as low-value [17] . Therefore, the objective of this scoping review was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations. A scoping review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews [18] . The protocol for this scoping review is registered on the PROSPERO website (CRD42020208072). Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from January 2010 to September 9, 2020. The search strategy was developed in Medline-Ovid (Table 1 ) and adapted for the other databases with assistance/support from librarians. Terms were built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization with text word synonyms of these terms, and more specific terms not having a Mesh term. Language filters were used to include articles written in English, German, Dutch, Danish, Norwegian, and Swedish. Animal studies Table 1 Search strategy in Medline (Ovid) # Medline (Ovid) 1 Diagnostic imaging/or cardiac imaging techniques/or imaging, three-dimensional/or neuroimaging/or radiography/or radionuclide imaging/or respiratory-gated imaging techniques/or tomography/or ultrasonography/or whole body imaging/ 2 exp Radiology/ 3 (MRI or x-ray* or xray* or ultrasound* or mammography or ultrasonography or DEXA or DXA or CT or radiograph* or radiolog* or tomography or imaging).tw 4 (CAT adj scan).tw 5 (bone adj scan).tw 6 (Magnetic adj resonance adj imaging).tw 7 1 or 2 or 3 or 4 or 5 or 6 8 exp Health Services Misuse/ or exp Medical Overuse/ 9 (Unnecessar* or overuse* or Inappropriate* or waste or wasted or low-value or overdiagn* or overutili* or misuse* or (Low adj value) or unwarrent or redundant).tw were excluded. The complete search strategy is available in Additional file 1. The search was expanded through a snowballing technique of hand-searching the reference lists of articles included following full-text screening. The records were archived using Thomson Reuters End-Note X9.3.3 library and duplicates were removed. All remaining records were transferred to Rayyan QCRI [19] where titles and abstracts were screened by EK, ERA, LvB-V, FC, and BMH for eligibility; 10% of citations were screened by two of the authors as quality assurance. Fulltext screening was completed by EK, ERA, AMK LvB-V, LJJS and BMH after a calibration meeting for quality assurance. Disagreements with regards to inclusion or exclusion were resolved through discussion and consensus among the authors. The inclusion and exclusion criteria are presented in Table 2 . In brief, empirical studies, including randomized controlled trials (RCTs), non-randomized controlled trials, cohort studies, descriptive qualitative studies, case studies, mixed-methods studies, and multi-methods studies assessing the value of radiological examinations for all patient groups were included. Data of the included studies were extracted using a summary table consisting of the following variables: author and year, country, design/methods, population, clinical setting, medical condition, low-value practice, reason for being low-value, alternative to low-value practice, and extent of use (when applicable). EK, ERA, AMK, and BMH extracted data after a calibration meeting where 10 publications were discussed for quality assurance. Narrative synthesis of included articles was completed. Articles were first categorized by adult or pediatric, the imaging modality, type of radiological examination evaluated, and the anatomical area imaged. The electronic database search identified 39,986 records (findings are documented in Additional file 1) and 17,429 duplicates were removed. A total of 22,557 records were screened for titles (and abstracts) in Rayyan QCRI [19] excluding 21,907 records. Through additional searches and snowballing, 44 additional records were found, resulting in 694 articles for full-text assessment. Following full-text screening 324 articles were excluded; an overview of the excluded articles and the reason for exclusion is presented in Additional file 2. Ultimately, 370 studies were included in the final synthesis. A PRISMA flow diagram of the screening and selection process is presented in Fig. 1 . Among the 370 included studies, 84 low-value imaging examinations were identified. Studies were conducted in 35 different countries, with most from the United States (n = 215) and Europe (n = 78). In-hospital imaging was the most common clinical setting (> 65%). Fourteen different study designs were employed among the included studies; most studies were designed as retrospective chart reviews (n = 262), cohort studies (n = 39), and cross-sectional studies (n = 19). Three hundred and eight studies included adult patients, 60 studied pediatric populations, and 2 studies included both adults and children. The characteristics of the included articles are provided in Additional file 3. Low-value diagnostic imaging in adults was evaluated in 264 studies. Across all imaging modalities, low-value use of computed tomography (CT), magnetic resonance imaging (MRI), and X-ray were most frequently reported. Outcomes measured for identifying low-value examinations varied across the studies and the most common were diagnostic yield (n = 213), and impact or change in treatment or management (n = 137). Importantly, the examinations defined as low-value were dependent on the clinical symptoms of patients e.g. a lumbar spine MRI is only valuable when the patient present with red flag symptoms. In the following sections, results are stratified by body areas (neurologic (central nervous system [CNS]), thoracic, musculoskeletal, abdominopelvic, vascular, whole body, breast, cardiac, and ear, nose, and throat, and neck imaging) and population type (i.e., adult versus pediatric population). Low-value imaging of the brain was explored in 49 studies . Specifically, routine use of head CT or repeat head CT in minor head injury and brain MRI were reported to be low-value for many clinical indications and conditions. The reason for being lowvalue was either low diagnostic yield where the majority of scans were reported to have no relevant findings, or a low rate in change of management for patients examined. To reduce the use of low-value neurologic imaging the studies indicated that the scan should be warranted based on patient symptoms rather than routine. Details are presented in Table 3 . Further, low-value imaging examinations of the cervical spine was identified in eleven studies [67-77] including routine imaging in trauma and routine follow-up after surgery in patients without symptoms (Table 4) . Thirty-eight studies reported chest X-rays to be lowvalue, while four studies reported on low-value use of chest CT . Of these, eighteen reported on chest X-rays in follow-up after procedures known to cause pneumothorax, where the X-ray did not change management in patients without symptoms [94] [95] [96] [97] [98] [99] [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] [110] [111] [112] . Further, routine chest X-ray was found to not change patient management when used as a pre and post op screening, at hospital admission, in medical checkups, or in staging of cervical and breast cancer. Repeat chest X-ray in trauma and ICU patients was found to be low-value and clinical symptoms should be used as an indicator to do an X-ray [78-93, 113, 118-120] . In CT, low-value examinations were found in emergency department patients, pleural effusion, and in staging of low-grade breast cancer as the diagnostic yield is Table 5 . Spine and hip or pelvis The most commonly reported low-value procedures in musculoskeletal imaging was for low back pain [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] . Ten studies demonstrated that X-ray, CT and MRI have a low impact on the treatment of patients without red flags, and 58.7% of MRI scans were negative [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] , imaging for pain in the rest of the spine was also shown as low-value [131] . In addition, change in management were only seen in < 1% of routine post-op X-rays after cervical (c)-or lumbar (l)-spine fusion [132] [133] [134] . Another study found that even though 93% of the referrals for lumbar MRI were appropriate according to guidelines, only 13% of the scans showed actionable findings [125] . In cases of pelvic fracture or trauma, routine pelvic X-ray had a low impact on treatment. The same was shown for MRI or CT in pelvic ring fracture [91, [135] [136] [137] . In hip fracture and hemiarthroplasty, routine post-op X-ray of the hip was low-value for patients without symptoms [138, 139] . One study showed that MRI is low-value in patients with hip pain when an X-ray is already acquired [140] . Details are presented in Table 6 . Upper and lower limb The second most common studied musculoskeletal low-value examination was MRI in knee pain without red flags, reported in eight studies [121, [141] [142] [143] [144] [145] [146] [147] . In addition, MRI of acute Achilles tendon rupture, X-ray of adjoined joints in ankle fracture, and CT of lower extremities stress fractures were also reported as low-value examinations [148] [149] [150] . X-ray of the knee changed management in 0-0.7% of patients after ligament reconstructions, tibia plateau fixation, and partial or total knee arthroplasty [151] [152] [153] [154] [155] [156] . In the upper limb, shoulder MRI in patients with shoulder pain or rotator cuff tear had a low impact on treatment [157] [158] [159] . X-ray of the shoulder in atraumatic shoulder pain or frozen shoulder had a low impact on clinical management [160, 161] . Further, orthopedic trauma, post-op, or post-splinting X-ray gave little to no change in management [162] [163] [164] [165] [166] [167] [168] [169] . MRI of the wrist in ligamentous injury changed the surgical plan in 28% of patients and was thus low-value for many patients [170] . On general use of imaging in the musculoskeletal system, four studies showed that skeletal CT for periarticular fractures (post-op) [171] , and long bone cartilaginous lesions (also MRI) [172] were of low-value. Details are presented in Table 7 . In abdominopelvic imaging, eighteen studies reported imaging with low-value in typical emergency or general medicine conditions [175] [176] [177] [178] [179] [180] [181] [182] [183] [184] [185] [186] [187] [188] [189] [190] [191] . X-rays for abdominal pain and upper gastrointestinal imaging (UGI) for reflux resulted in a change in management in only 4% of patients and is often of poor diagnostic quality [187] [188] [189] . In acute pancreatitis, < 1.2% of CT and MRI examinations yielded relevant findings [175] [176] [177] [178] . Lowvalue imaging related to surgery or other invasive procedure in the abdomen was reported in seven studies [192] [193] [194] [195] [196] [197] [198] . Contrast esophagogram had a low impact on treatment in suspected esophageal perforation, and anastomotic leaks after esophagectomy [195, 197, 198] . In addition, staging of cancer using a different kind of MRI or CT in the abdominal/pelvic area was described as low-value in six studies for various types of cancer [199] [200] [201] [202] [203] . In urology, abdominal CT in urolithiasis had a low impact on the treatment of patients with selflimiting episodes or at follow-up [190, [204] [205] [206] . Renal MRI Hip Hip pain After XR-low impact on treatment [140] ultrasound in new-onset acute kidney injury to screen for hydronephrosis led to changes in management in just 1.8% of patients in one study [207] . In addition, retrograde urethrography in penile fracture had a low impact on treatment in patients without hematuria or urethrorrhagia [208] . An overview of low-value imaging in abdominopelvic imaging is given in Table 8 . The two most reported low-value vascular imaging examinations were CTA of the chest in patients with low risk of pulmonary embolism (7 studies) and ultrasound in patients with low risk for deep venous thrombosis (5 studies). Negative result was demonstrated in 97% of examinations [210] [211] [212] [213] [214] [215] [216] [217] [218] [219] [220] [221] . Further, CTA of the abdominal aorta after endovascular aneurysm repair (EVAR) in patients without endoleak 1 month after the EVAR procedure, was identified as low-value [222] [223] [224] . Ultrasound was reported to be better as surveillance for EVAR patients as ultrasound increased the negative predictive value to 97.6% [222] [223] [224] . In addition, CTA was shown to be of low-value in patients with blunt vertebral artery injuries and vascular injuries of the lower limbs [225, 226] . Details are presented in Table 9 . Whole body imaging examinations were identified as low-value in trauma and oncology in six studies. Whole body scanning in trauma should be made only when clinically indicated [227] [228] [229] [230] [231] [232] . In addition, one study identified CT in soft tissue infections as low-value, with the exception of intra-abdominal abscesses [233] . In oncology, whole body imaging used for staging and follow-up was identified as low-value in 18 studies [58, [234] [235] [236] [237] [238] [239] [240] [241] [242] [243] [244] [245] [246] [247] [248] [249] [250] . Details on low-value whole body imaging in oncology is presented in Table 10 . Before UGI No change in management Use last image hold in fluoroscopy [181] Constipation No change in management Clinical examination is sufficient [183] Abdominal pain 4-12% relevant findings [187, 189] Abdominal CT Urolithiasis 1.8% change in management [190, 204, 206] Complicated gallstone disease Low diagnostic accuracy Clinical examination or US is superior to CT [179] Acute appendicitis Avoid for reducing radiation dose US should be used first. Only use CT if US is inconclusive [191] Acute pancreatitis < 1.2% relevant findings [175] [176] [177] [178] Post-op abdominal CT Urolithiasis 2.6% relevant findings [205] CT pelvis Gastric cancer 2% change in patient management [209] Abdominal MRI Acute pancreatitis < 1.2% relevant findings [175] [176] [177] [178] Abdominal US After CT -Poly trauma 1.1% relevant findings [185] Pre-op Abdominal US Bariatric surgery 1.2% change in surgical plan [194] Abdominopelvic CT/MRI Uterine cancer 10% relevant results [199] Prostate cancer 1% relevant results [200, 201] Liver MRI Colorectal cancer After CT -No new findings [202] Follow-up adrenals MRI Adrenal cancer 4% change in surgical plan [203] Retrograde urethrography Penile fracture No change in management Use for patients with hematuria or urethrorrhagia [208] Renal US New-onset acute kidney injuryhydronephrosis 1.8% change in management [207] Contrast esophagogram Suspected esophageal perforation Low diagnostic accuracy CT is a superior examination [197] Anastomotic leaks after esophagectomy Low diagnostic accuracy CT and endoscopy are better examinations [195, 198] UGI Gastroesophageal reflux 4.5% change in management [188] Post-op UGI Swallowing difficulty Low diagnostic accuracy CT is a better examination [193, 196] After laparoscopy No change in management [192] In breast cancer follow-up, mammography or MRI of the breasts less than 1-year after treatment were described as low-value [255] [256] [257] [258] [259] [260] [261] [262] . Follow-up of benign breast tumors with short intervals showed only 0-0.5% identified malignancy in three studies, thus low-value to the majority of patients [260] [261] [262] . According to one study [263] on male patients only, 0.9% of breast ultrasound or mammography found malignancy. Details are presented in Table 11 . Stress imaging such as myocardial perfusion imaging (MPI) and echocardiography were described as lowvalue in low risk patients, and patients with more than one risk factor for cardiac disease [264, 265] . In patients with infective endocarditis, only 10% of the findings in FDG PET/CT of the heart led to changes in treatment [266] . Routine transthoracic echocardiography in acute ischemic stroke patients had relevant findings in 38% of patients, however only 8.5% of patients had additional work-up [267] . Elective coronary angiography investigating coronary heart disease had relevant findings in 40% of patients in one study [268] . Yet another study found that during coronary angiography left ventriculography is of poor quality [269] . An overview of lowvalue cardiac imaging is given in Table 12 . Post-operative thyroid cancer ultrasound was found to be low-value as 98% of the scans were negative [270] and the risk for relapse is small [271] . Furthermore, increased use of ultrasound uncovered more benign and low-risk cancers [272, 273] . Radioactive iodine scanning found 17% concordant findings with earlier examinations. Thus, fine needle aspiration should be used in diagnostics instead of imaging [274] . Thyroid ultrasound as follow-up after lobectomy found tumor or recurrence in only 1.5% of patients [275] . According to one study, in patients with secondary hyperparathyroidism routine pre-op Tc-99 m-sestamibi scans are unnecessary as nodules are found during surgery [276] . X-ray and CT of the sinuses in acute rhinosinusitis did not change patient management [277] . In patients with facial fractures, X-ray and CT was identified as low-value in five studies [278] [279] [280] [281] [282] , as imaging did not change the management of the patient. One study introduced the use of ultrasound combined with an X-ray, instead of CT in zygomatic arch and mandibular fractures [281] . Another study described MRI of the face for juvenile ossifying fibroma as lowvalue [283] . Imaging of templar bones was described as low-value in patients with chronic Eustachian tube dysfunction and pre-op for cochlear implants [284, 285] . Details are presented in Table 13 . The use of low-value imaging in pediatric patients was reported in 62 studies presented in Table 14 [168, . The most frequently reported low-value examinations were CT and MRI of the head/brain, CT and X-ray related to trauma, chest X-ray, and musculoskeletal X-rays in fracture follow-up. The proportion of low-value examinations varied greatly in the 103 included studies reporting proportion. Seven studies explored low-value imaging in adults on an overarching level with several medical conditions and modalities, showing an overall rate of low-value imaging of 2-31% [346] [347] [348] [349] [350] [351] [352] . The proportion of low-value imaging examinations in specific body areas differed from 4 to 100% (86 studies], and varied both between and within different countries and clinical settings. The results are presented in Fig. 2 Routine transthoracic echocardiography Acute ischemic stroke 8.5% change in management [267] Elective coronary angiography Coronary heart disease 40% relevant findings Use risk stratification to screen patients [268] Left ventriculography during angiography Coronary heart disease Low diagnostic accuracy Echocardiography, nuclear scintigraphy, or MRI have better diagnostic results [269] PET/CT Infective endocarditis 10% change in treatment [266] [168] echocardiography, carotid imaging, chest X-ray, X-ray in acute rhinosinusitis, CTA in pulmonary embolism, early-stage breast cancer staging, acute pancreatitis, and special imaging for pre-op templar bone CT in cochlear implantation, and CT/MRI in long bone cartilaginous lesions. In addition, one study reported a sevenfold increase in knee MRI, while there was a reduction in knee arthroscopy [145] . In pediatrics the use of low-value examinations varied between 3.6 and 93.7% (11 studies) [286, 297, 299, 301, 314, 315, 320, 321, 356, 388, 389] . Abdominal CT in appendicitis (3.6%), repeat CT in trauma patients (5%) and C-spine CT in cervical spine injury (13%) were the least over-used examinations. Head CT (50-93.7%), CT scan in case of blunt abdominal trauma (18-80%) and pretransfer CT in trauma patients (66%) were the lowvalue examinations most used. In summary, through this scoping review, we found 84 different low-value imaging examinations performed among both adult and pediatric populations, for all imaging modalities, and body areas. [190, [204] [205] [206] , chest CTA [210] [211] [212] [213] [214] [215] [216] and ultrasound lower limb veins in patients with low risk of thrombosis [217] [218] [219] [220] [221] were most prominent among adult populations. When analyzing the extent in use of low-value imaging additional examinations were identified; low interval DEXA screening, echocardiography in patients with low risk of cardiac disease, carotid imaging in syncope, X-ray in rhinosinusitis, and MRI for pain in the hip or upper extremities [140, 157-159, 173, 277, 365, 366, 369, 373, 376] . The variation in the proportion of low-value imaging was large (2-100% inappropriate or unnecessary examinations) and varied between studies of the same examination. There is no obvious threshold in proportion for when to define examinations as low-value. Even though the examinations found in this review are low-value on a group level, certain patient sub-groups or individual Fig. 2 Overview of proportion of low-value examinations in different patient complains/diagnosis. The blue bar represents the minimum rate and the combined blue and orange bar represents the maximum inappropriate rate patients could have clinical findings justifying the use of imaging. However, in several studies there were identified a rate of ≥ 90% inappropriate imaging examinations. This provides a reason for altering the utilization of these examinations in practice. We found this to be the case in: repeat head or routine trauma CT, echocardiography, MRI in hip, knee and upper extremity pain, CT/MRI in acute pancreatitis, and pre-op templar bone CT in cochlear implantation [40-42, 54, 140, 141, 143, 145-147, 173, 176, 177, 229, 284, 357, 369, 388] . Our review found additional examinations that are potentially low-value to the examinations presented in the Choosing Wisely list [17, 390] . Additionally, we report the extent of low-value imaging. Our additional findings merit further investigation, including chest X-ray after invasive lung procedures such as CVC placement, chest tube placement/removal, biopsies, and other procedures [94-112, [339] [340] [341] , musculoskeletal followups after fractures or invasive procedures, MRI and X-ray in atraumatic shoulder or upper-extremity pain [138, 139, 151-156, 160-167, 169, 173, 323-329, 334, 336] and staging and follow-up procedures in cancers other than breast, cervical, prostate, and lymphoma [58, 172, 199, 202, 203, 209, 235-237, 239-241, 243-245, 247-249] . Hence, while we confirm previous findings, we also add new findings to the literature. Not all examinations in the Choosing Wisely list were included in this in this review such as cardiac imaging in asymptomatic patients or head CT in patients with sudden hearing loss [390] . This could be caused by the search being incomplete (for instants excluding screening programs), evidence of their lowvalue was given before 2010 or that some of the Choosing Wisely recommendations were based on clinical experience rather than research reports. There are many ways to measure low-value imaging, including diagnostic yield, diagnostic accuracy, and impact/change in treatment or management, where diagnostic yield (n = 213) and change in patient management (n = 137) were most common. By applying the Fryback and Thornbury value model as stated by Brady et al. [391] , measures of change in patient management and trends in imaging and related treatments, seems a better way to identify low-value imaging, rather than measuring diagnostic accuracy [391] . This scoping review has strengths and limitations in its methods. Although the search in databases was systematic and exhaustive, the cut-off was set at 2010, which excluded examinations identified as low-value imaging or adopted to clinical practice before 2010. Due to the large number of citations retrieved from the database searches, a wide range of inconclusive studies, studies identifying conditional low-value imaging, and articles reporting clinical practice guidelines were excluded. Hence, a wide range of supportive studies were excluded as the inclusion criteria were strict. Therefore, it is likely that there are several studies of low-value examinations that are not included in this review. Accordingly, the excluded studies in Additional file 2 may provide useful information for those who want to pursue specific examinations. The quality of included studies was also not assessed; it is likely that the included studies were of variable quality, limiting the strength of the conclusions made in this review. While the strict inclusion criteria may to some extent compensate for the lack of study quality assessment, quality assessment is not required [392] as the purpose of a scoping review is to identify and map the available evidence. While this review provides a valuable overview of identified low-value imaging, especially useful for clinicians and policymakers to be able to take actions to reduce overuse of diagnostic imaging. However, contextual assessment is needed before changing clinical practice. In addition, the risk of ionizing radiation or contrast media has not been considered in this analysis, this would be interesting issues to consider in later studies. There is also need for research on barriers and facilitators for reducing low-value imaging care to assess where to target policy changes, guidelines, and clinical practice. In this study, we provide a comprehensive list of lowvalue radiological examinations for both adults and children. Our overview reaches beyond earlier published lists and adds information on the quantity of low-value imaging utilization, which reportedly varied from 2 to 100% among included studies. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after chest interventions, fracture followup and cancer staging, or follow-up were the most frequently identified low-value imaging examinations. This overview can be of great value for clinicians, policymakers, and researchers for revising appropriateness criteria and planning de-implementation. Efforts should be made to reduce the extension and variation of inappropriate imaging which generates huge opportunity costs and is potentially harmful to patients. Expert Panel on effective ways of investing in Health (EXPH) Tackling wasteful spending on health Radiology and value-based health care Cancer risks attributable to low doses of ionizing radiation: assessing what we really know Side effects of radiographic contrast media: pathogenesis, risk factors, and prevention Addressing overutilization in medical imaging Awareness, utilization, and education of the ACR appropriateness criteria: a review and future directions Reductions in high-end imaging utilization with radiology review and consultation Improving health and social care through evidence-based guidance Evidenced-based radiology? A single-institution review of imaging referral appropriateness including monetary and dose estimates for inappropriate scans To choose or not to choose: evaluating the effect of a choosing wisely knowledge translation initiative for imaging in low back pain by emergency physicians Why are clinical practice guidelines not followed? Head CT for minor head injury presenting to the emergency department in the era of choosing wisely Trends in low-value carotid imaging in the veterans health administration from Lumbosacral spinal imaging for patients presenting to the emergency department with nontraumatic low back pain Overuse of diagnostic testing in healthcare: a systematic review PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation Rayyan-a web and mobile app for systematic reviews Overuse of computed tomography for minor head injury in young patients: an analysis of promoting factors Unnecessary head computed tomography scans: a level 1 trauma teaching experience Overuse of brain CT scan for evaluating mild head trauma in adults Head CT scan in emergency room: is it still abused? Quantification and causes analysis of overprescription in an Italian Emergency review and meta-analysis of medical record reviews Imaging during low back pain ED visits: a claims-based descriptive analysis Spine radiography in the evaluation of back and neck pain in an orthopaedic emergency clinic In-hospital postoperative radiographs for instrumented single-level degenerative spinal fusions: utility after intraoperative fluoroscopy Utility of postoperative radiographs after anterior lumbar interbody fusion with or without posterior instrumentation The utility of repeated postoperative radiographs after lumbar instrumented fusion for degenerative lumbar spine Advanced imaging lacks clinical utility in treating geriatric pelvic ring injuries caused by low-energy trauma Straight leg elevation to rule out pelvic injury Routine pelvic X-rays in asymptomatic hemodynamically stable blunt trauma patients: a meta-analysis The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures No additional value of routine check X-rays after internal fixation of hip fractures Unnecessary magnetic resonance imaging of hips: an economic burden to patients and the healthcare system The use of MRI in evaluating knee pain in patients aged 40 years and older Indications for and clinical procedures resulting from magnetic resonance imaging of the knee in older patients: are we choosing wisely? Is prescription of knee MRI according to standard clinical guideline? The utility of MRI scans for a painful knee in the elderly patient Trends in knee magnetic resonance imaging, arthroscopies and joint replacements in older Australians: still too much low-value care? Appropriateness of knee MRI prescriptions: clinical, economic and technical issues Appropriateness of magnetic resonance imaging requested by primary care physicians for patients with knee pain Diagnostic accuracy of various imaging modalities for suspected lower extremity stress fractures MRI is unnecessary for diagnosing acute Achilles tendon ruptures: clinical diagnostic criteria Relevance of adjacent joint imaging in the evaluation of ankle fractures Limited utility of routine early postoperative radiography after primary ACL reconstruction Radiographic images are inapplicable for a precise evaluation of the femoral tunnel position following MPFL reconstruction Routine postoperative radiographs after tibia plateau fixation have minimal impact on patient care Radiographic imaging in the postanesthesia care unit is unnecessary after partial knee arthroplasty Effect of immediate postoperative portable radiographs on reoperation in primary total knee arthroplasty Pre-discharge postoperative radiographs after primary total knee replacement: tradition or science? Reducing unnecessary shoulder MRI examinations within a capitated health care system: a potential role for shoulder ultrasound Inappropriate requests for magnetic resonance scans of the shoulder A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management Routine plain radiographs in the setting of atraumatic shoulder pain: are they useful? Routine X-rays for suspected frozen shoulder offer little over diagnosis based on history and clinical examination alone Postoperative radiographs after pinning of supracondylar humerus fractures: are they necessary? Utility of postoperative radiography in routine primary total shoulder arthroplasty Radiographs late in the follow up of uncomplicated distal radius fractures: are they worth it? Clinical outcome and financial implications The role of early post-operative radiographs following distal radius fracture fixation with a volar locking plate: time for change? Utility and cost analysis of radiographs taken 2 weeks following plate fixation of distal radius fractures Omitting routine radiography of traumatic distal radial fractures after initial 2-week follow-up does not affect outcomes Evaluation of computed tomography use in emergency department orthopedic trauma patients Post-splinting radiographs of minimally displaced fractures: good medicine or medicolegal protection? Appropriateness of the use of magnetic resonance imaging in the diagnosis and treatment of wrist soft tissue injury Postoperative computed tomography for articular fractures: a systematic review Overutilization and cost of advanced imaging for long-bone cartilaginous lesions Magnetic resonance imaging in evaluating workers' compensation patients Evaluation of imaging utilization prior to referral of musculoskeletal tumors: a prospective study Computed tomography scan imaging in diagnosing acute uncomplicated pancreatitis: usefulness vs cost Use of CT and MRI in emergency department patients with acute pancreatitis Practice and yield of early CT scan in acute pancreatitis: a Dutch Observational Multicenter Study The utility of early cross-sectional imaging to evaluate suspected acute mild pancreatitis Value of initial radiological investigations in patients admitted to hospital with appendicitis, acute gallbladder disease or acute pancreatitis Pre-procedural scout radiographs are unnecessary for routine pediatric fluoroscopic examinations Appropriateness of CT scans for patients with non-traumatic acute abdominal pain Utility of plain abdominal radiography in adult ED patients with suspected constipation Emergency department abdominal x-rays have a poor diagnostic yield and their usefulness is questionable Costs and role of ultrasound follow-up of polytrauma patients after initial computed tomography Utility of repeated abdominal CT scans after prior negative CT scans in patients presenting to ER with nontraumatic abdominal pain Plain abdominal radiography in acute abdominal pain-is it really necessary? Does an upper gastrointestinal study change operative management for gastroesophageal reflux? The role of plain radiographs in patients with acute abdominal pain at the ED Radiological imaging of patients with suspected urinary tract stones: national trends, diagnoses, and predictors Diagnostic value of ultrasound compared to CT in patients with suspected acute appendicitis Upper gastrointestinal swallow study following bariatric surgery: institutional review and review of the literature Utility of immediate postoperative upper gastrointestinal contrast study in bariatric surgery Role of routine abdominal ultrasound before bariatric surgery: review of 937 patients The diagnostic value of routine contrast esophagram in anastomotic leaks after esophagectomy Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary? Utility of routine oral contrast study for detecting postesophagectomy anastomotic leak-a systematic review and meta-analysis Preoperative imaging of uterine malignancy: a low-value service Unnecessary imaging for the staging of low-risk prostate cancer is common Quantifying downstream impact of inappropriate staging imaging in a cohort of veterans with low-and intermediate-risk incident prostate cancer Use of liver magnetic resonance imaging after standard staging abdominopelvic computed tomography to evaluate newly diagnosed colorectal cancer patients Do additional imaging studies change operative management in patients undergoing adrenalectomy? Routine deferred computed tomography for patients with suspected urolithiasis is low-value healthcare Stone-free rate after treating kidney stones exceeding 10 mm via flexible ureteroscopy: can endoscopic assessment replace low-dose computed tomography control? Is CTKUB the gold standard in assessing flank pain with diagnostic uncertainty? A one-year review of 228 cases What is the appropriate use of renal sonography in an inner-city population with new-onset acute kidney injury? Penile fracture and its treatment: is retrograde urethrograghy necessary for management of penile fracture? Value and necessity of pelvic CT in gastric cancer staging: an observational study Increased emergency department computed tomography use for common chest symptoms without clear patient benefits Assessment of the current D-dimer cutoff point in pulmonary embolism workup at a single institution: retrospective study The determinants of productivity in medical testing: intensity and allocation of care Overtesting for suspected pulmonary embolism in American emergency departments: the continuing epidemic CT pulmonary angiography: an over-utilized imaging modality in hospitalized patients with suspected pulmonary embolism Computed tomography pulmonary angiography is overused to diagnose pulmonary embolism in the emergency department of academic community hospital Underuse of risk assessment and overuse of computed tomography pulmonary angiography in patients with suspected pulmonary thromboembolism Overuse of compression ultrasound for patients with lower extremity cellulitis Is it useful to also image the asymptomatic leg in patients with suspected deep vein thrombosis? Evaluating the use of a negative D-dimer and modified low wells score in excluding above knee deep venous thrombosis in an outpatient population, assessing need for diagnostic ultrasound Venous duplex ultrasound surveillance in the neurosurgical population: a single-center quality improvement initiative Four-extremity venous duplex ultrasound for suspected deep venous thrombosis is an anachronism Surveillance computed tomographic arteriogram does not change management before 3 years in patients who have a normal post-EVAR study Postoperative surveillance and long-term outcomes after endovascular aneurysm repair among medicare beneficiaries The value of the initial post-EVAR computed tomography angiography scan in predicting future secondary procedures using the Powerlink stent graft Follow-up imaging of traumatic vertebral artery dissections is unnecessary in asymptomatic patients Overutilization of cross-sectional imaging in the lower extremity trauma setting Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study Inefficiencies in a rural trauma system: the burden of repeat imaging in interfacility transfers Utility of additional CT examinations driven by completion of a standard trauma imaging protocol in patients transferred for minor trauma Torso computed tomography can be bypassed after thorough trauma bay examination of patients who fall from standing Blunt trauma abdominal and pelvic computed tomography has low yield for injuries in more than one anatomic region Pretransfer CT scans are frequently performed, but rarely helpful in rural trauma systems The increased use of computed tomography scanning for diagnosing superficial soft tissue infections: a disturbing trend of increased radiation with no benefit Risk-based patient selection for magnetic resonance imagingtargeted prostate biopsy after negative transrectal ultrasound-guided random biopsy avoids unnecessary magnetic resonance imaging scans Pattern of use of positron emission tomography/computed tomography (PET/ CT) scan in non-colorectal gastrointestinal cancers at KFSHRC, Riyadh, Saudi Arabia The role of preoperative positron emission tomography/computed tomography (PET/CT) in patients with high-risk melanoma Clinical staging of patients with early esophageal adenocarcinoma: does FDG-PET/CT have a role? Staging of primary breast cancer is not indicated in asymptomatic patients with early tumor stages ABVD alone and a PET scan complete remission negates the need for radiologic surveillance in early-stage, nonbulky Hodgkin lymphoma Use of positron emission tomography to detect recurrence and associations with survival in patients with lung and esophageal cancers Futility of imaging to stage melanoma patients with a positive sentinel lymph node Is advanced imaging in earlystage breast cancer ever warranted? Reconciling clinical judgment with common quality measures Staging chest computed tomography and positron emission tomography in patients with pancreatic adenocarcinoma: utility or futility? HPB (Oxford) The value of preoperative positron emission tomography/computed tomography in node-negative endometrial cancer on magnetic resonance imaging Low-dose PET/CT and full-dose contrast-enhanced CT at the initial staging of localized diffuse large B-cell lymphomas Imaging for distant metastases in women with early-stage breast cancer: a population-based cohort study Clinical indications and impact on management: fourth and subsequent posttherapy follow-up (18)F-FDG PET/CT scans in oncology patients Utility of routine post-therapy surveillance imaging in diffuse large B-cell lymphoma Limited utility of surveillance imaging for detecting disease relapse in patients with non-Hodgkin lymphoma in first complete remission In support of the Choosing Wisely campaign: perceived higher risk leads to unnecessary imaging in accelerated partial breast irradiation? Is bone scintigraphy necessary in initial staging of prostate cancer patients? Hellenic Use of bone scan during initial prostate cancer workup, downstream procedures, and associated Medicare costs Comparison of bone scintigraphy and Ga-68 prostate-specific membrane antigen positron emission tomography/computed tomography in the detection of bone metastases of prostate carcinoma Characterising potential bone scan overuse amongst men treated with radical prostatectomy Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial Preoperative breast magnetic resonance imaging and contralateral breast cancer occurrence among older women with ductal carcinoma in situ Preoperative breast magnetic resonance imaging and contralateral breast cancer occurrence among older women with breast cancer The role of early post-treatment mammography after breast conservation therapy Is short-interval mammography necessary after breast conservation surgery and radiation treatment in breast cancer patients? Is 6-month radiologic imaging necessary after benign breast biopsy? Review of literature and multicenter experience The value of 6-month interval imaging after benign radiologic-pathologic concordant minimally invasive breast biopsy Utility of short-interval follow-up mammography after a benignconcordant stereotactic breast biopsy result Overuse of imaging the male breast-findings in 557 patients The role of myocardial scintigraphy in the assessment of cardiovascular risk in patients with end-stage chronic kidney disease on the waiting list for renal transplantation High numbers of false-positive stress tests are the result of inappropriate testing Clinical usefulness of FDG-PET/CT for identification of abnormal extra-cardiac foci in patients with infective endocarditis Utility of transthoracic echocardiography in diagnostic evaluation of ischemic stroke Low diagnostic yield of elective coronary angiography Use and overuse of left ventriculography Thyroid ultrasound and the increase in diagnosis of low-risk thyroid cancer Follow-up of benign thyroid nodules-can we do less? Analysis of postoperative ultrasonography surveillance after hemithyroidectomy in patients with papillary thyroid microcarcinoma: a multicenter study Postoperative ultrasonography surveillance in patients with follicular thyroid carcinoma: a multicenter study Radioactive iodine scanning is not beneficial but its use persists for euthyroid patients Long-term follow-up ultrasonography after lobectomy in papillary thyroid microcarcinoma patients: a single-center study Are Tc-99m-sestamibi scans in patients with secondary hyperparathyroidism and renal failure needed? Overuse of diagnostic tools and medications in acute rhinosinusitis in Spain: a population-based study (the PROSINUS study) Evaluation of concomitant orbital floor fractures in patients with head trauma using conventional head CT scan: a retrospective study at a level II trauma center Postoperative radiographs after open reduction and internal fixation of mandibular fractures: clinical need or unnecessary radiation? Diagnosing isolated nasal fractures in the emergency department: are they missed or overdiagnosed? Ten years experience of 535 forensic cases A comparative study on the diagnostic utility of ultrasonography with conventional radiography and computed tomography scan in detection of zygomatic arch and mandibular fractures Postoperative radiographs after maxillofacial trauma: sense or nonsense? Is computed tomography an adequate imaging modality for the evaluation of juvenile ossifying fibroma? A comparison of 2 imaging modalities (computed tomography and magnetic resonance imaging) Are routine preoperative CT scans necessary in adult cochlear implantation? Implications for the allocation of resources in cochlear implant programs Role of imaging before Eustachian tube dilation using the Bielefeld balloon catheter Is there over use of computed tomography scan in paediatric head injury patients? Utilization of CT imaging in minor pediatric head, thoracic, and abdominal trauma in the United States Clinically-important brain injury and CT findings in pediatric mild traumatic brain injuries: a prospective study in a Chinese reference hospital Use of computed tomography and diffusion weighted imaging in children with ventricular shunt The role of computed tomography in following up pediatric skull fractures Necessity of repeat head computed tomography after isolated skull fracture in the pediatric population Is repeat head computed tomography necessary in children admitted with mild head injury and normal neurological exam? Routine repeat brain computed tomography in all children with mild traumatic brain injury may result in unnecessary radiation exposure The role of neuroimaging in children and adolescents with recurrent headachesmulticenter study Site locked headaches in paediatric patients do not require routine brain imaging and rarely have a serious aetiology Investigating the necessity of computed tomographic scans in children with headaches: a retrospective review Imaging utilization in children with headaches: current status and opportunities for improvement Utility of intraoperative and postoperative radiographs in pediatric cochlear implant surgery Pediatric cervical spine injury in the United States: defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers Pediatric liver injury: physical examination, fast and serum transaminases can serve as a guide Using patient characteristics to predict usefulness of abdominal computed tomography in children Missed opportunities to decrease radiation exposure in children with renal trauma Alvarado scores predict additive value of magnetic resonance imaging in workup of suspected appendicitis in children Is the scout out? The utility of scout radiographs in the pediatric upper gastrointestinal examination Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review Pediatric abdominal X-rays in the acute care setting-are we overdiagnosing constipation? Cureus Role of bedside ultrasound in determining the position of umbilical venous catheters Is Routine upper gastrointestinal contrast study necessary prior to laparoscopic gastrostomy tube placement in children? Routine gastrostomy tube placement in children: does preoperative screening upper gastrointestinal contrast study alter the operative plan? Gastro esophageal reflux: an over investigated entity in neonates and infants Inappropriate use of ultrasound in management of pediatric cryptorchidism Misuse of ultrasound for palpable undescended testis by primary care providers: a prospective study Ultrasound diagnosis of multicystic dysplastic kidney: is a confirmatory nuclear medicine scan necessary? Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure Identifying children at very low risk for blunt intra-abdominal injury in whom CT of the abdomen can be avoided safely Re-evaluation of liver transaminase cutoff for CT after pediatric blunt abdominal trauma Trends in CT utilization for pediatric fall patients in US emergency departments Mechanism of injury alone is not justified as the sole indication for computed tomographic imaging in blunt pediatric trauma Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk Are CT scans obtained at referring institutions justified prior to transfer to a pediatric trauma center Repeat computed tomography scans after pediatric trauma: results of an institutional effort to minimize radiation exposure Surveillance computed tomography imaging and detection of relapse in intermediate-and advanced-stage pediatric Hodgkin's lymphoma: a report from the Children's Oncology Group The utility of radiographs prior to pin removal after operative treatment of supracondylar humerus fractures in children Outcome after pin fixation of supracondylar humerus fractures in children: postoperative radiographic examinations are unnecessary a retrospective study of 252 Gartland-III and 12 flexion-type supracondylar humerus fractures The utility of routine postoperative radiographs after pinning of pediatric supracondylar humerus fractures The utility of the early postoperative follow-up and radiographs after operative treatment of supracondylar humerus fractures in children Imaging of the elbow in children with wrist fracture: an unnecessary source of radiation and use of resources? Does early radiography alter remanipulation rates in paediatric forearm fractures? Are unnecessary serial radiographs being ordered in children with distal radius buckle fractures? Low-risk criteria for pelvic radiography in pediatric blunt trauma patients Usefulness of pelvic radiographs in the initial trauma evaluation with concurrent CT: is additional radiation exposure necessary? Family history in developmental dysplasia of the hip: should we follow-up? Do we need to follow up an early normal ultrasound with a later plain radiograph in children with a family history of developmental dysplasia of the hip? Routine radiographic follow-up is not necessary after physeal fractures of the distal tibia in children Can we make a diagnosis with radiographic examination alone in calcaneal apophysitis (Sever's disease)? Are postoperative standing radiographs relevant before hospital discharge in adolescent idiopathic scoliosis? Are routine postoperative radiographs necessary during the first year after posterior spinal fusion for idiopathic scoliosis? A retrospective cohort analysis of implant failure and surgery revision rates Role of preoperative 3D CT reconstruction for evaluation of patients with esophageal atresia and tracheoesophageal fistula The routine use of chest radiographs after chest tube removal in children who have had cardiac surgery Is a chest radiograph required after removal of chest tubes in children? Intracavitary electrocardiography-guided positioning of central vascular access device can spare unnecessary ionizing radiation exposure in pediatric patients Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis Chest radiography in children hospitalized with bronchiolitis Appropriateness and diagnostic yield of inpatient pediatric echocardiograms. Congenit Heart Dis Is routine preoperative transthoracic echocardiography necessary in newborns with myelomeningocele? Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? Do family physicians request ultrasound scans appropriately? Appropriateness of radiology test requests by an emergency department: a retrospective study Survey of inappropriate use of magnetic resonance imaging Clinically unjustified diagnostic imaging-a worrisome tendency in today's medical practice Finding the truth in medical imaging: painting the picture of appropriateness for magnetic resonance imaging in Canada Appropriate use of medical imaging in two Spanish public hospitals: a cross-sectional analysis The use of bedside chest radiography at a university hospital. Data on a two-week period Trends in use of daily chest radiographs among US adults receiving mechanical ventilation Preoperative testing before low-risk surgical procedures Choosing wisely: determining performance of unjustified imaging in a large healthcare system Appropriateness of knee MRI prescriptions in a hospital of Birjand Measuring the frequency and variation of unnecessary care across Canada Assessing volume and variation of low-value care practices in the Netherlands Prevalence of the different lumbar back pain etiologies in Spain: results from a large observational study in 306 centers (the SMILE study) Quality assurance using routine data: overdiagnosis by radiological imaging for back pain Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years Has Choosing Wisely(R) affected rates of dual-energy X-ray absorptiometry use? Overuse of short-interval bone densitometry: assessing rates of low-value care Clinical value of the Ottawa ankle rules for diagnosis of fractures in acute ankle injuries Overuse of diagnostic brain imaging among patients with stage IA non-small cell lung cancer Overtesting and undertesting in primary care: a systematic review and meta-analysis Prevalence and clinical characteristics of inappropriate myocardial perfusion imaging tests at a community hospital Diagnostic workup of early-stage breast cancer: can we choose more wisely? Comparison of the appropriateness of myocardial perfusion imaging in men versus women Trends in low-value carotid imaging in the veterans health administration from Appropriateness of imaging for lung cancer staging in a national cohort Overuse of imaging for staging low risk prostate cancer Common reasons that asymptomatic patients who are 65 years and older receive carotid imaging Increasing receipt of high-tech/ high-cost imaging and its determinants in the last month of taiwanese patients with metastatic cancer Unwarranted imaging for distant metastases in patients with newly diagnosed ductal carcinoma in situ and stage I and II breast cancer Regionallevel correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for the choosing wisely campaign A multicenter evaluation of the appropriate use of single-photon emission tomography myocardial perfusion imaging research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year submit your research ? Choose BMC Low yield of stress imaging in a population-based study of asymptomatic patients after percutaneous coronary intervention Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer in the United States A national study of the use of asymptomatic systemic imaging for surveillance following breast cancer treatment (AFT-01) Clinical routine use of dopamine transporter imaging in 516 consecutive patients Cutaneous melanoma follow-up: appropriateness of requests for ultrasound tests-the S.Gallicano National Referral Centre Experience Assessment of inpatient multimodal cardiac imaging appropriateness at large academic medical centers. Cardiovasc Ultrasound Adherence to national comprehensive cancer network(R) guidelines for testicular cancer Indications of brain computed tomography scan in children younger than 3 years of age with minor head trauma Histologic and clinical characteristics can guide staging evaluations for children and adolescents with rhabdomyosarcoma: a report from the Children's Oncology Group Soft Tissue Sarcoma Committee Reducing Inappropriate use of diagnostic imaging through the choosing wisely initiative Radiology in the era of value-based healthcare: a multi-society expert statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations The online version contains supplementary material available at https:// doi.