ACR Appropriateness Criteria®
Clinical Condition: Routine Admission and Preoperative Chest Radiography
Variant 1: Asymptomatic; history and physical unremarkable.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, chest, routine admission |
2 |
|
| X-ray, chest, preoperative |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 2: Acute cardiopulmonary findings by history or physical.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, chest, routine admission |
9 |
|
| X-ray, chest, preoperative |
9 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 3: Chronic cardiopulmonary disease in the elderly (older than age 65), previous chest x-ray within 6 months available.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, chest, preoperative |
6 |
|
| X-ray, chest, routine admission |
4 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 4: Chronic cardiopulmonary disease in the elderly (older than age 65), previous chest x-ray within 6 months not available.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| X-ray, chest, routine admission |
8 |
|
| X-ray, chest, preoperative |
8 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Routine chest radiography obtained at the time of admission to hospital and in the preoperative setting has been a common practice. This guideline will address the use and efficacy of this practice in both settings. Most routine chest radiography is done in the preoperative setting rather than as part of a routine admission for medical reasons. However, several studies have addressed the use of routine chest radiography prior to nonsurgical procedures, at the time of admission for various medical conditions, and for all elderly patients admitted to the hospital. Several studies have also addressed the use of routine chest radiography prior to interventional but nonsurgical procedures. One study regarding the routine utilization of chest radiography prior to biliary lithotripsy reviewed a group of 75 patients referred for this procedure. All patients underwent posteroanterior (PA) and lateral chest radiographs. No significant pulmonary or pleural disease was noted in any of the patients. A similar study documented that routine chest radiography prior to angiography was not necessary in the absence of any specific clinical indications. In a series of 240 patients, no angiogram was postponed or canceled because of abnormalities detected on the routine chest radiograph.
Routine Admission Chest Radiography
Several studies have addressed the utility of routine chest radiographs in patients admitted for various clinical conditions, including acute gastrointestinal hemorrhage, acute stroke, and in the elderly. None of these studies supported the use of routine radiography in these patient groups unless there were clinical indications of cardiac or pulmonary disease. One research team prospectively studied 1,000 consecutive admissions to an acute geriatric ward and demonstrated that 35%-50% of these patients had little or no clinical indication for routine chest radiograph examination and that omitting this study in these patients would not have resulted in any significant chest conditions. The remainder of the population had signs and symptoms, other evidence of pulmonary or cardiovascular disease, or other clinical features that indicated the need for chest radiography. Of the 35% with no indication for chest radiography, 5.5% did have some abnormality, but in only 3 (less than 1%) was this considered to be significant. Of the 65% who had some indication for a chest radiograph, 17% of the total had known chronic cardiac or pulmonary disease and in these, radiologic findings did not contribute to further management.
A more recent study recorded the chest radiographic findings in 200 patients who were admitted to an acute psychiatric ward. The chest radiograph was normal in 82% of these patients. Relevant abnormalities were noted in 5%, but all of them were already known. In all cases, the screening test was of no practical value. Another group of researchers studied the impact of routine admission chest radiography on the treatment of patients on internal medicine wards at a Veterans Administration hospital in California. In a population of 294 patients, 36% had abnormalities noted on the routine admission chest radiograph. However, the findings were previously known to be chronic and stable in 86 patients and were new in only 20. Treatment was changed because of the chest radiographic results in only 4% of the patients, and in only one of these patients would appropriate treatment probably have been omitted had the chest radiograph not been obtained. The recommendation from this study was that routine chest radiographs should not be ordered solely because of admission. It is of particular interest to note that this patient population had a very high prevalence of both chronic cardiac and pulmonary disease.
Preoperative Chest Radiography
In the United States, more than $30 billion is spent on preoperative testing annually. Chest radiography is included in many centers for routine preoperative evaluation. As is evident, the study is a relatively low-cost, low-risk procedure to screen or evaluate for occult or known cardiopulmonary disease. However, in the past two decades, the efficacy of its use, along with other routine preoperative laboratory studies, has been the issue of multiple studies.
In 1979, the Royal College of Radiologists published a multicenter study that retrospectively examined 10,619 preoperative chest radiographs in patients undergoing elective noncardiopulmonary surgery. The conclusion was that the preoperative chest radiograph did not influence the decision to operate or the choice of anesthetic. Another study evaluated the usefulness of preoperative chest radiographs in 905 patients based upon risk factors including history of malignancy, recent history of smoking, exposure to toxic chemicals, or signs and symptoms of recent infection. It was concluded that a group of patients does exist for whom preoperative chest radiographs will predictably demonstrate no serious abnormalities and that this low-risk population constitutes the majority of the surgical population. A separate study evaluated the utility of preoperative chest radiographs in 3,883 patients and found that routine preoperative chest radiographs could be eliminated without undesirable effects on patient care or outcome. In a study of 1,000 patients, the recommendation was that preoperative chest radiographs should only be ordered when there is a cardiopulmonary abnormality suspected on the basis of the history and physical examination. The study emphasized that preoperative chest films should not be routine in any age group. A meta-analysis performed on 21 studies written between 1966 and 1992 reported that abnormalities were found in approximately 10% of routine preoperative chest radiographs. Only 1.3% of the abnormalities were unexpected on the basis of the history and physical examination. The test results were of sufficient importance to cause modification of management in only 0.1% of these cases. In 1997, a review of 46 empirical studies that included preoperative chest radiographs was published. The researchers concluded that the available evidence does not support the practice of routine chest radiographs for all patients.
A recent study in 2004 investigated the use of preoperative testing in morbidly obese patients undergoing gastric bypass. These patients are generally considered at high risk for perioperative and postoperative complications. Preoperative chest radiographs revealed abnormalities in only 4%, none of which required preoperative intervention. The authors concluded that preoperative chest radiography was not mandatory for such patients as a routine preoperative evaluation, but could be used selectively on the basis of medical history.
Despite the lack of support in the literature, there remains wide variation in the use of preoperative chest radiographs. Some proponents believe that the study is an extension of a general physical examination and, as such, should be routinely included in a preoperative evaluation. However, it has been shown that there is insufficient diagnostic yield to warrant the use of nonindicated chest radiography as part of a routine physical examination. Especially in a healthy population, screening chest radiographs have a high cost-benefit ratio. Scheduling a patient for surgery does not improve the benefit. An operation, per se, does not constitute a risk factor requiring chest radiographs.
Others have cited medico-legal reasons as a justification for including chest radiographs in the preoperative evaluation. However, data are available to mitigate this contention. Routine preoperative chest radiography is not supported in the medical literature and, therefore, cannot be considered the standard of care. Also, several authors have shown that many abnormalities detected in laboratory screening tests should not be pursued. It can be argued that the risk of failure to follow-up an abnormal test presents a greater exposure to a lawsuit than not ordering a routine study.
One researcher reviewed the records of 369 surgical patients and determined that in 9% of cases the preoperative film was helpful for comparison in the management of postoperative chest radiographic findings. However, the actual effect of the baseline preoperative film on patient care could not be determined in this retrospective analysis. Another research team studied 1,262 patients who had a preoperative chest radiograph. Sixteen percent went on to have postoperative films. Their conclusion was that the comparisons had no "therapeutic consequences in any case." In the paper by the Royal College of Radiologists, 70% of postoperative complications developed in patients without serious cardiopulmonary disease. On this basis, and assuming there is at least some value in having preoperative films for comparison, the authors argued that it would be necessary to radiograph up to 90% of all surgical patients to be reasonably sure of having a baseline available for all those in whom a postoperative pulmonary complication develops.
Several authors have argued that there are adverse effects that result from routine preoperative chest radiographs. First is the unnecessary radiation exposure. Additional expense is another concern. Also, surgery may be delayed due to incidental findings or improper communication. As with routine nonsurgical chest radiographs, there is the additional cost and morbidity in the further evaluation of incidental findings such as solitary pulmonary nodules.
In 1984, the Royal College of Radiologists published a set of guidelines for the ordering of preoperative chest radiographs. Their parameters included scheduled cardiopulmonary surgery, age, suspected metastatic disease, acute respiratory symptoms, and recent immigration from a country where tuberculosis (TB) is endemic. Since then, multiple authors have proposed their recommendations and guidelines for the use of preoperative chest radiographs. Other parameters presented include smoking, emergency cases, immunosuppressed patients, and American Society of Anesthesiologists (ASA) grades. Unfortunately, most of these publications base their conclusions upon statistical evaluation of the diagnostic yield of the chest radiograph interpretation. Some of the "positive" reports have included such findings as rib fractures, linear scarring, sub-segmental atelectasis, pleural scarring and mild increased cardiothoracic ratio which would likely have little to no effect on perioperative management. The real measure of the efficacy of routine chest radiographs in the preoperative setting is the impact on patient management and outcome analysis. It is in this context that a prospective study would greatly contribute to determining the appropriateness criteria to establish which patients would truly benefit from preoperative chest radiographs.
This review of the literature supports the summary of one group of researchers who carried out an exhaustive review of the literature for all types of preoperative testing including routine preoperative and admission chest radiographs. They concluded that:
- No randomized controlled trials of the effectiveness of routine preadmission or preoperative chest radiographs have been published. All available evidence reports the results of case series.
- Few studies allow the outcome of routine chest radiographs to be distinguished from those of indicated chest radiographs, and fewer have gone beyond abnormalities to examine the impact on clinical management.
- Findings from routine preoperative chest radiographs are reported as abnormal in 2.5%–37% of cases and lead to a change in clinical management in 0%–2.1% of cases. The effect on patient outcome is unknown.
- Both abnormality yield and impact on patient management rise with age and poorer anesthesiology status.
- Limited evidence on the value of chest radiography as a baseline measure suggests that it will be of value in less than 5% of patients.
In 2005, a meta-analysis of manuscripts published between 1966 and 2004 addressed the value of screening preoperative chest radiographs. All eligible studies were reviewed, and data were extracted individually by two authors. Of the reported studies, the diagnostic yield of the preoperative chest radiograph was found to increase with age. However, most of the abnormalities consisted of chronic disorders such as cardiomegaly and chronic obstructive pulmonary disease which were already identified clinically. When further investigations were performed, the proportion of patients who had a change in management was low (10% of investigated patients). Postoperative pulmonary complications were similar between patients with preoperative chest radiographs (12.8%) and patients who did not have preoperative chest radiographs (16%). The authors concluded that an association between preoperative screening chest radiographs and a decrease in morbidity and mortality could not be established. The conclusion appears warranted that chest radiographs should not be performed on patients younger than age 70 and without risk factors. For patients older than age 70, there is insufficient evidence against performance of routine chest radiographs.
The available evidence does not support a policy for performing routine admission or preoperative chest radiographs for all patients. Although there is no evidence showing that such a policy would lead to worse outcomes for patients, the finding that only 2% of chest radiographs lead to a change in management of patients suggests a high level of cost and inconvenience with potentially limited benefits.
Because of the lack of adequate prospective studies, particularly studies that deal with the effect of admission and preoperative chest radiographs on patient outcome, a recommendation from the American College of Radiology that these studies not be obtained may be somewhat premature. However, given the current evidence, routine preoperative and admission chest radiographs are not recommended except when the following conditions exist:
- Acute cardiopulmonary disease is suspected on the basis of history and physical examination.
- There is a history of stable chronic cardiopulmonary disease in an elderly (older than age 65) patient without a recent chest radiograph within the past six months.
