To the Editor: The views of Mendelson and Murray1 regarding inappropriate use of diagnostic imaging and how it might be reduced are timely and important. Unless governments, doctors, the medical imaging industry and consumers acknowledge the significant barriers to Mendelson and Murray’s proposed changes, the number of inappropriate tests will grow.

The authors argue that radiologists need to be more active in vetting requests. This is often hindered by the lack of relevant clinical information from referrers about the indications for tests. Broadhurst et al2 found that 34% of unselected Australian requests for shoulder ultrasound contained “no tangible information to assist the radiological examination”.

Surveys of doctors in the United Kingdom found that their knowledge of the radiation delivered by various imaging tests, relative to that of a chest x-ray, was poor.3 This lack of knowledge makes it difficult, if not impossible, for doctors to inform patients about the risks and benefits of an imaging test.

The Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists was set up in 2004 to develop a knowledge base of evidence-based best practice in radiology. To date, it has commissioned over 25 quality-related projects in areas such as development of information for consumers, best practice standards for radiology requests, and audit–feedback analysis of radiation dosage in paediatric computed tomography. The QUDI Program and the National Institute of Clinical Studies have sponsored fellowships in evidence implementation, training radiologists in the art and science of supporting clinicians’ use of evidence-based, appropriate diagnostic imaging. The results of QUDI projects are used in strategies to improve the use of radiology.

The Australian Medical Association is advocating that general practitioners have access to magnetic resonance imaging, arguing that it would reduce costs and radiation exposure.4 However, this does not address the issue of appropriate consultative referral, and has the potential to simply add to the burgeoning diagnostic imaging budget rather than directly benefiting patients.

A multifaceted approach to change is required, involving the referrer, the consumer and the entire radiology industry. This must be based on best-practice, patient-focused use of radiology. Radi-ologists are central to providing advice on the most appropriate imaging procedures and reducing the burden of inappropriate imaging. This is likely to require changes to practice and to legislation.

To the Editor: The authors of the editorial “Towards the appropriate use of diagnostic imaging”1 canvass possible strategies to improve the appropriateness of requests for diagnostic imaging. One strategy that research suggests may be effective is feedback provided by the providers of diagnostic services.2,3 Discussion of the feedback could, and should, be supported by federal government funding, perhaps via Divisions of General Practice, and should attract continuing professional development points for the general practitioners involved.

In reply: We thank Kenny and colleagues for their comments and congratulate the members of the Quality Use of Diagnostic Imaging (QUDI) Program of the Royal Australian and New Zealand College of Radiologists on their continuing efforts. We are also grateful to Frank for his constructive suggestion.

We entirely agree that a multifaceted approach is needed to improve the appropriateness of referral for diagnostic imaging. We believe that the majority of general practitioners are willing to be educated and guided with regard to their referring practices. However, to do so they require up-to-date guidelines that are easily accessible in electronic form, based on evidence and consensus, practicable and able to be integrated into their everyday desktop applications,1 much like pharmaceutical guidelines are currently. The QUDI Program has chosen to focus on producing guidelines on selected topics, while we, with our “Diagnostic Imaging Pathways”,2 have chosen to work towards a more comprehensive clinical decision support and educational application. Of course, the two approaches are entirely complementary.

It also behoves radiologists, at an individual level, to interact with their referrers, to vet requests (ensuring that requests are appropriate and contain adequate clinical information, as emphasised by Kenny and colleagues) and act as the consultants they were trained to be. Sometimes this may be to their short-term economic detriment. However, one hopes that such short-term disadvantage would be countered in the longer term by greater professional satisfaction and a better relationship with referrers, who are likely to remain loyal to those radiologists on whom they can rely for advice and education in addition to trustworthy image interpretation.