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Article History

Received: 18 August 2024

Accepted: 29 May 2025

First Online: 5 July 2025

Declarations

:

: 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 that gave a favorable opinion to the study, and all significant changes were noted in the public trial registry. Randomization and intervention in the MIDAS study were executed at a departmental level. Individuals were neither recruited nor randomized. 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 cluster or organizations’ behalf. Guardians of the clusters in the MIDAS study were the chairs of each participating department or delegated persons. Individual subjects were not able to withdraw, as the intervention is implemented in the radiological imaging referral system. Physicians could however at all times choose not to follow the recommendations provided by the CDSS. A Data Safety Monitoring Board (DSMB) was formed, comprising three independent researchers. No safety issues arose for which the DSMB had to be consulted.

: Not applicable.

: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Kröncke 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, Canon Medical Systems, Bracco 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. Dijk receives (or received in the past 36 months) research funding from the Gordon and Betty Moore Foundation. Dr. Claudia Wollny has no conflicts of interest to report. Dr. Halfmann has no conflicts of interest to report. Dr. Jansen receives (or received within the past 36 months) research funding outside the submitted work from DFG (German Scientific Society), has received speaker fees from Philips Medical, Rapid AI, mRAY, Boehringer and Bayer and has received consultant honoraria from TÜV Süd, Radiologie Holding and Stryker. Dr. Hunink receives (or received in the past 36 months) Royalties from Cambridge University Press for a textbook on Medical Decision Making, reimbursement of travel 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.