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Letters to the Editor |
1 Department of Radiology, McMaster University, Faculty of Health Sciences
1200 Main Street West, Hamilton, ON, Canada L8N 3Z5 Deceased.
Editor:
It was a pleasure indeed to find in the November 2004 issue of Radiology the article entitled "Routine Chest Radiography in a Primary Care Setting" by Dr Tigges and associates (1). To my knowledge, this is the first publication that provides high-quality evidence that "routine chest radiography has low diagnostic yield in asymptomatic primary care patients" (1). I am very much aware that this evidence is needed.
When I served as chair of the Task Force on Standards and Guidelines for Radiological Practice of the Canadian Association of Radiologists, we attempted in 1998 to develop guidelines for chest x-rays in asymptomatic populations. We defined a chest x-ray as "routine" when it was ordered and performed even though the patient history and physical examination provided no clinical indication or suspicion of morbidity. We included chest x-rays in routine health examinations; routine preadmission, preoperative, and pre-employment chest x-rays; and chest x-rays in lung cancer screening. The guidelines were developed by the McMaster Diagnostic Imaging Practice Guidelines Initiative for the Chest X-ray Working Group, which I chaired. It included representatives from anesthesia, family medicine (primary care), internal medicine, medical and radiation oncology, occupational medicine, respirology, and surgery, as well as a clinical epidemiologist and qualified radiologists.
For each of the categories of routine chest x-rays, we established objectives, options, outcomes, and perspectives (values). We critically appraised the quality of existent evidence. We assessed benefits and harms and developed recommendations based on these reviews. Unfortunately, we found that the evidence for or against the use of chest x-rays was limited in all categories, and most of the reviews were small case series. Therefore, we decided against the submission of our reviews for publication.
Validation was obtained by means of submission of the proposed guidelines for peer review and approval by the Canadian Association of Radiologists. It was decided to recommend against the use of all routine chest x-rays in patients in whom an adequate history and physical examination could be done. On the strength of these recommendations, hospitals developed policies against the use of routine preadmission and preoperative chest x-rays. The number of pre-employment chest x-rays declined substantially. The College of Physicians and Surgeons of Ontario, as the governing body of the profession in this province, adopted and published our guidelines in 1999 (2).
It is unfortunate that these recommendations and policies have had no impact whatsoever on the ordering patterns of primary care physicians. Routine chest x-rays, as part of annual health assessment and screening of smokers, are still requested in large numbers. Therefore, it is essential to have good evidence that can stand up to critical appraisal about the uselessness of routine chest x-rays. In addition, we must, of course, consider radiation exposure and cost, which are becoming critical problems in the United States (3,4), as well as Canada. The radiation exposure with a modern chest radiograph may be negligible—but I am sure that we do not have to make a living by exposing human beings to unnecessary ionizing radiation. Cost, on the other hand, is a critical issue, and it would be interesting to estimate the annual cost of unnecessary routine x-rays in the United States.
My thanks to Dr Tigges and his associates for filling in one of our "evidence gaps."
References
Department of Radiology, The Emory Clinic, Building A
1365 Clifton Road NE, Atlanta, GA 30322
e-mail: stefan_tigges{at}emoryhealthcare.org
We thank Dr Stolberg for his generous remarks concerning our article (1). Our experience with policy recommendations is similar to his. In 1998, we surveyed both academic and private practice radiologists about their use of the American College of Radiology's musculoskeletal appropriateness criteria and found that only 30% of radiologists used the criteria (2). The proportion using the criteria was the same for both private practice and academic radiologists.
References
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