Beyond Imaging Overuse: Reframing Appropriateness as a Framework for Value-Based and Sustainable Radiology

Diagnostic imaging is central to contemporary healthcare, but increasing demand has intensified concerns regarding inappropriate and low-value examinations. Imaging appropriateness should be understood as a multidimensional quality framework rather than a simple reduction in examination volume. This narrative review synthesizes evidence on clinical outcomes, radiation protection, healthcare costs, organizational efficiency, equity, incidental findings, and environmental sustainability. A structured PubMed search was complemented by targeted database and institutional searches and selective citation tracking. Low-value imaging may disrupt diagnostic pathways through diagnostic uncertainty, unnecessary follow-up, avoidable radiation exposure, additional costs, waiting-list pressure, and environmental burden. Mitigation strategies include referral guidelines, clinical decision support, radiologist-led vetting, standardized incidental findings management, and audit and feedback. Their effects vary by setting and outcome: improved referral scores do not necessarily reduce utilization or improve patient outcomes. Environmental estimates depend on imaging modalities, electricity supply, and assessment boundaries, while proposed artificial intelligence applications require prospective validation. We translate this evidence into an operational pathway linking examination justification, modality and protocol selection, reporting, follow-up, and service evaluation. Imaging appropriateness therefore requires reducing low-value examinations while preserving diagnostic safety and timely, equitable access to clinically beneficial imaging.