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In Reply We are pleased that the American College of Radiology (ACR) “has worked for decades” to reduce unwarranted imaging and lower radiation dose, but given the substantial rise in unnecessary tests,1,2 and the dramatic variation in the radiation doses used in performing them even when patients are evaluated for the same clinical questions,3,4 it appears that the ACR’s strategy is not working. Perhaps the problem would be even worse without the efforts of the ACR, but the current situation cannot be considered acceptable. An independent assessment of the ACR’s appropriateness criteria determined that they had no effect on the use of imaging or the appropriateness of imaging when tested among more than 3900 imaging providers across 8 states.5 This finding is consistent with what has been found in many other aspects of clinical care. Voluntary guidelines are a weak lever to change physician practice behavior6 especially if the guidelines are not based on clear and convincing evidence7 or if they rely upon biased evidence or evidence perceived to be biased.8
Smith-Bindman R, Bindman AB. Imaging More Wisely—Already At Work—Reply. JAMA Intern Med. 2016;176(6):870–871. doi:10.1001/jamainternmed.2016.2075
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