Kudu E, Hizli N, Danış F, Altun M. Defensive medicine and advanced imaging overuse in emergency departments: A focused review of imaging stewardship and overcrowding. World J Radiol 2026; 18(10): 127912 [DOI: 10.4329/wjr.127912]
Corresponding Author of This Article
Emre Kudu, MD, Associate Professor, Researcher, Department of Emergency Medicine, Marmara University School of Medicine, Muhsin Yazıcıoğlu Caddesi No. 10, İstanbul 34899, Türkiye. ekudu@marmara.edu.tr
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Emergency Medicine
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review-article
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Kudu E, Hizli N, Danış F, Altun M. Defensive medicine and advanced imaging overuse in emergency departments: A focused review of imaging stewardship and overcrowding. World J Radiol 2026; 18(10): 127912 [DOI: 10.4329/wjr.127912]
World J Radiol. Oct 28, 2026; 18(10): 127912 Published online Oct 28, 2026. doi: 10.4329/wjr.127912
Defensive medicine and advanced imaging overuse in emergency departments: A focused review of imaging stewardship and overcrowding
Emre Kudu, Naz Hizli, Faruk Danış, Mustafa Altun
Emre Kudu, Mustafa Altun, Department of Emergency Medicine, Marmara University School of Medicine, İstanbul 34899, Türkiye
Naz Hizli, Department of Pediatrics, Marmara University Pendik Training and Research Hospital, İstanbul 34899, Türkiye
Faruk Danış, Department of Emergency Medicine, Bolu Abant İzzet Baysal University Medical School, Bolu 14030, Türkiye
Author contributions: Kudu E designed overall concept, outline, and design of the manuscript, led the writing of the manuscript, and performed the literature investigation; Hizli N, Danış F, and Altun M aided in the literature search, engaged in the interpretation and discussion of the findings, and meticulously revised and refined the manuscript; and all authors read and approved the final version of the manuscript to be published.
AI contribution statement: Artificial intelligence tools were used solely for English language editing of the manuscript and for the preparation of Figure 1. The authors reviewed and verified all text and assume full responsibility for the integrity, accuracy, originality, and scientific validity of the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Emre Kudu, MD, Associate Professor, Researcher, Department of Emergency Medicine, Marmara University School of Medicine, Muhsin Yazıcıoğlu Caddesi No. 10, İstanbul 34899, Türkiye. ekudu@marmara.edu.tr
Received: September 10, 2026 Revised: September 26, 2026 Accepted: October 12, 2026 Published online: October 28, 2026 Processing time: 48 Days and 15.9 Hours
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.
Core Tip: Advanced imaging overuse in emergency departments is driven by diagnostic uncertainty, time pressure, malpractice concerns, patient expectations, consultant requests, and system-level workflow constraints. This narrative review synthesizes current evidence linking defensive medicine and low-value imaging to radiology bottlenecks, prolonged emergency department throughput, unnecessary costs, incidental findings, and clinician workload. It also proposes a conceptual reciprocal-pressure framework, in which crowding and defensive imaging reinforce each other, that has not been tested experimentally. It also summarizes reported mitigation strategies, including clinical decision rules, computerized clinical decision support, Choosing Wisely initiatives, shared decision-making, audit and feedback, and multidisciplinary imaging stewardship.
