Association between radiological CDSS availability and quality of imaging referrals graded using RI-RADS

Deficiencies in clinical information within imaging referrals can affect imaging justification and the quality of radiology reporting. This pragmatic controlled before-and-after implementation study evaluated cervical and lumbar spine X-ray referral quality in an emergency department before and after the availability of a standalone clinical decision support system (CDSS) alongside existing workflows. Referrals were assessed using the reason for exam imaging reporting and data system (RI-RADS), grades A-D. Approximately three-quarters were classified as deficient, grade D. Logistic regression and mixed-effects modeling demonstrated no statistical significance between-group effect, although temporal confounding prevents firm conclusions regarding CDSS effectiveness. Both groups showed reductions in deficient referrals over time, with no additional improvement associated with CDSS availability beyond observed secular trends. These findings highlight challenges associated with standalone CDSS implementation and emphasize the importance of workflow and health-technology integration when designing decision support to improve imaging referral quality.