In recent years, there has been an increased awareness of uncontrolled healthcare spending. The American Board of Internal Medicine’s “Choosing Wisely” initiative aims at identifying tests and treatments that add little value to individual and public health (ABIM Foundation 2015).
The chest x-ray (CXR) is an inexpensive, fast, and informative diagnostic tool for characterizing a wide array of cardiopulmonary pathology, and it is the most widely used radiographic test in the world. In the US, about 70 million CXRs are performed each year, and about 60% of these are thought to be for routine screening purposes (National Institute of Standards and Technology 2005) (Tape 1986).
Given its ubiquity, and in line with discussions about appropriate and cost-conscious testing, there has been long-standing debate about when to perform CXRs in the Emergency Department (ED) setting. One of the prominent dialogues centers on the question of when to obtain a “routine admission chest x-ray” (RACXR) for patients being admitted to the hospital. In many hospitals, policies are in place to obtain admission CXRs in the ED, irrespective of patient symptoms or the reason for admission.
Risks, Costs and Consequences
The Agency for Healthcare Research and Quality, the World Health Organization, the Environmental Protection Agency and several radiologic societies have statements against universal RACXR, but their statements provide little specifics in advising who should and shouldn’t be imaged (AHRQ 2011) (EPA 2015) (American College of Radiology 2011). Similar to all tests, performing the RACXR on inappropriate patients carries inherent risks, costs, and consequences. These risks include:
- Delay: Unnecessary delay to admission, contributing to ED congestion. ED crowding has been associated with increased mortality. (McCusker 2014)
- Incidentalomas: Lung nodules requiring follow up. This exposes the patient to the risks and costs of further diagnostic testing, and exposes ED physicians to the responsibility of advising follow-up. Relatedly, screening CXR for lung cancer has not been shown to be beneficial.
- Radiation: Although the radiation dose of a CXR is relatively low, diagnostic radiographs are thought to account for about 1% of all malignancies. A UK study estimated that 700 cases of cancer are caused by radiographs in the UK each year. (Berrington 2004)
- Monetary cost: Reflexive RACXR imposes a significant cost on the health system, as well as the individual. Many patients do not have insurance, and many patients live below the poverty line. Including radiology fees, most CXRs cost around $150. For comparison, this is equivalent to 2-3 days of work at minimum wage. Many patients seen at public hospitals are undocumented, have no health insurance, and receive minimum wage. Physicians should be aware of the potential burden that reflexive testing can place on their patients.
Impact of Admission CXR on Patient Management
Literature on the topic has tended to evaluate the impact RACXR has on patients’ hospital stay. These studies have suggested that in the vast majority of patients admitted to the hospital from the ED–even in those with known, pre-existing cardiopulmonary disease– a RACXR did not impact or alter care during the hospital stay.
Take, for example, a study by Verma et al, performed at a hospital where all patients admitted from the ED receive an RACXR. Over a 4-month period, they evaluated the hospital courses of 126 patients deemed to be admitted to the hospital for diagnoses or symptoms not requiring a pre-admission CXR (but who still received a RACXR). Among these 126 patients, only 5 (3.8%) had findings on RACXR that necessitated a change in management. Three patients with known CHF had their diuretic dose altered, and two non-verbal elderly patients were found to have a pneumonia (Verma 2011).
Caveats to Ditching the RACXR
The discussion of appropriate testing and cost-conscious care is an important one. However, the discussion around CXRs, specifically in the setting of the ED, have lacked emphasis on the role of the ED as a safety-net institution, and on the unique features of the many at-risk populations seen there. EDs, especially those in urban public hospitals, serve recent immigrants, prisoners, the homeless, and people with significant mental health and substance use disorders (hereafter referred to as the underserved).
These patients may have infrequent or fragmented contact with the health system. Due to language barriers and social factors, physicians are often unable to take the time to obtain a full medical history to adequately determine who may require a screening test. Recent immigrants, chronic alcoholics and injection drug users are at very high risk for occult pulmonary disease, and are often not in a condition to fully provide an account of their symptoms.
Lastly, and perhaps most importantly, EDs are the primary point of contact for patients at highest risk for latent tuberculosis. Although the overall incidence of TB is declining in the US, multi-drug resistant tuberculosis (MDR-TB) remains a significant public health threat, and a full discussion of the costs associated with CXR in the ED should take into account the cost of missing a case of latent TB. The WHO estimates that the cost of treatment for a patient with MDR-TB is close to $300,000. This is the cost of treatment alone, and does not take into account the millions of dollars required for public health tracking of patient contacts, potential exposures, and follow up testing (Centers for Disease Control and Prevention, 2014).
Take Home Points
- The RACXR is not indicated in all patients. Patients with good access to the healthcare system, those with recently documents CXRs, and those with non-cardiopulmonary complaints are not likely to benefit from an RACXR in the ED.
- Inappropriate use of RACXR may delay admission and increase ED crowding, provide undue radiation exposure, and impose unnecessary costs to the healthcare system and to individual patients.
- Underserved populations, including recent immigrants, the homeless, prisoners, and others are at high risk for occult cardiopulmonary disease and TB and warrant a screening RACXR.
ABIM Foundation. Choosing Wisely – An Initiative of the ABIM Foundation. 2015. Link
National Institute of Standards and Technology. Low-Cost Manufacturing Process Technology for Amorphous Silicon Detector Panels: Applications in Digital Mammography and Radiography. 2005. Link
Tape TG, Mushlin AI. Diagnostic Decision: The Utility of Routine Chest Radiographs. Ann Intern Med. 1986;104:663-670. doi:10.7326/0003-4819-104-5-663. PMID: 3516043
Agency for Healthcare Research and Quality. Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria® routine admission and preoperative chest radiography. 2011. Link
Environmental Protection Agency, Federal Guidance Report No. 14, “Radiation protection guidance for diagnostic and interventional X-ray procedures. 2015. Link
American College of Radiology Appropriateness Criteria: Routine admission and preoperative chest radiography. 2011. Link
McCusker J et al. Increases in Emergency Department Occupancy Are Associated With Adverse 30-day Outcomes. Acad Emerg Med 2014; 21:1092–1100. PMID: 25308131
Berrington de Gonzalez A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363 (9406): 345-51. PMID: 15070562
Verma V et al. The utility of routine admission chest x-ray films on patient care. Eur J Intern Med 2011; 22: 286–288. PMID: 21570649
Centers for Disease Control and Prevention. Treatment Practices, Outcomes, and Costs of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis, United States, 2005–2007. Link