Analytical Investigation of the Determinants of Diagnostic Imaging Referral Appropriateness at Teaching Hospitals in North East Nigeria

Inappropriate diagnostic imaging referrals, representing both under-referral for clinically indicated examinations and over-referral for investigations unlikely to change management, are a significant source of radiation dose, healthcare resource waste, and diagnostic delay in Nigerian teaching hospitals. In North East Nigeria, where imaging capacity is limited and radiation dose management resources are constrained, referral appropriateness analysis fills a critical gap. This study analytically investigates the determinants of diagnostic imaging referral appropriateness at teaching hospitals in Borno, Adamawa, and Yobe States. A prospective cohort study enrolls 500 consecutive referrals for diagnostic imaging across CT, X-ray, and ultrasound modalities at three teaching hospitals, with referral appropriateness independently assessed by consultant radiologists against the Royal College of Radiologists iRefer guidelines. Multivariable logistic regression in SPSS identifies referring clinician-level, patient-level, and system-level determinants of inappropriate referral. Available imaging referral literature from North East Nigeria identifies incomplete clinical information on referral forms and absence of clinical indication guides for referring clinicians as the strongest determinants of inappropriate referral. The Evidence-Based Referral Framework and clinical decision support theory provide the analytical reference. Findings are expected to reveal inappropriate referral rates between 20 and 35 percent, with junior clinicians, emergency department referrals, and plain radiography categories showing highest inappropriateness rates. Recommendations address mandatory clinical indication training for interns and junior doctors, referral form redesign, and clinical decision support tools at North East teaching hospitals. Keywords: referral appropriateness, diagnostic imaging, North East Nigeria, teaching hospitals, iRefer guidelines.