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Article History

Received: 20 April 2025

Revised: 6 September 2025

Accepted: 3 October 2025

First Online: 6 November 2025

Compliance with ethical standards

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: The guarantor for this paper is M.G. Myriam Hunink.

: The authors declare the following financial interests/personal relationships, which may be considered as potential competing interests: Dr. Dijk receives (or received in the past 36 months) research funding from the Gordon and Betty Moore Foundation. Dr.rer.nat. Wollny has no conflicts of interest to report. Dr. Kroencke receives (or received within the past 36 months) research funding outside the submitted work from The Bavarian Centre for Cancer Research, the national Network University Medicine (NUM) and Siemens Healthineers, has received honoraria for educational symposia from SIRTEX Medical, Boston Scientific and Abbott Medical GmbH and re-imbursements of expenses related to his work in the executive committee and congressional events of the Cardiovascular and Interventional Radiological Society of Europe. Dr. Hunink receives (or received in the past 36 months) Royalties from Cambridge University Press for a textbook on Medical Decision Making, reimbursement of expenses to attend the 2022 European Congress of Radiology from the European Society of Radiology (ESR) for work on the ESR guidelines for imaging referrals, and research funding from the American Diabetes Association, the Netherlands Organization for Health Research and Development, Netherlands Educational Grant (“Studievoorschotmiddelen”), and the Gordon and Betty Moore Foundation. The technical implementation and integration of the iGuide within the computer order entry systems was supported by the ESR iGuide team. The iGuide team exported scored session data. ESR played no role in the study design; analysis and interpretation of data; writing of the report; and the decision to submit the report for publication.

: No complex statistical methods were necessary for this paper.

: Consent for a cluster to participate in the MIDAS study was obtained through a guardian who possesses the legitimate authority to make decisions on the department’s behalf. Guardians of the clusters were the chairs of each participating department. Individuals were not able to withdraw, as the trial intervention is implemented in the imaging referral system. Physicians may, however, at all times choose not to follow the recommendations provided by the CDSS. The study does not collect any identifiable information from patients or physicians; therefore, no additional individual consent for data collection was sought. This procedure was approved by the relevant medical ethics review committee bodies.

: Approval from the Medical Research Ethics Committee (MREC) was obtained under protocol numbers 20-069 (Augsburg), B 238/21 (Kiel), 20-318 (Lübeck) and 2020-15125 (Mainz). The trial is registered in the Clinical Trials Register ( ) under trial number NCT05490290. The study was conducted according to the principles of the WMA Declaration of Helsinki. All changes to the study protocol were shared with the MREC, which gave a favorable opinion to the study, and all significant changes were noted in the public trial registry. The presented descriptive study in this paper based on the MIDAS study is not part of the original MIDAS study protocol.

: Some data entries from study subjects have been previously reported in the main MIDAS trial results (Dijk et al [ ]). The present study includes entries that were excluded from the main trial, as the originating department could not. Additionally, the present study contains detailed information on sex-specific inappropriateness, which was not reported in the main trial.

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