Defensive medicine and advanced imaging overuse in emergency departments: A focused review of imaging stewardship and overcrowding.

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Abstract

Emergency departments (EDs) are encountering a significant increase in patient volumes, compounded by greater reliance on advanced radiological imaging modalities. This trend is most evident for computed tomography and magnetic resonance imaging, with expanding use of emergency ultrasonography in selected pathways. These modalities are essential for time-sensitive diagnosis, triage, and risk stratification. Under diagnostic uncertainty, time pressure, crowding, and medico-legal concern, imaging may exceed evidence-based thresholds. Imaging overuse, also described as overutilization, has been associated with radiology bottlenecks, longer ED turnaround times, higher healthcare costs, and worse overcrowding. It may also expose patients to radiation, contrast-related risks, incidental findings, downstream testing, overdiagnosis, and avoidable financial burden. Excessive imaging demand further increases the workload of radiologists and emergency physicians and may contribute to reporting delays, cognitive fatigue, and burnout. This focused narrative review synthesizes the clinical, behavioral, and system-level drivers of overuse of advanced imaging in EDs, and proposes a conceptual reciprocal-pressure framework linking crowding, diagnostic uncertainty, defensive ordering, and radiology bottlenecks. It also discusses mitigation strategies, including clinical decision rules, computerized clinical decision support, Choosing Wisely initiatives, artificial intelligence-supported tools, shared decision-making, audit and feedback, and multidisciplinary imaging stewardship. The evidence supporting these strategies is heterogeneous, and their reported effects are not equivalent. The aim is to support safer, more efficient, and patient-centered diagnostic workflows in emergency care.

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