According to an old World Health Organization (WHO) survey (cited in [
The real value of radiology for the referring physician and the patient can be assessed by analyzing its clinical utility. One obvious way of doing this is to register and analyze how and when radiology has induced treatment changes or been used to monitor treatment. A large number of papers report the lack of clinical utility or efficacy of routine admission [
The aim of the current study has been to retrospectively evaluate the clinical influence of chest radiography in a large number of examinations by (1) assessing the relationship between the radiologic outcome and the clinical response, (2) assessing the relationship between outcome and influence on clinical treatment, and (3) assessing to which extent the radiologic outcome was noted and referred to in the medical records.
One thousand consecutive office-hour chest radiographs requested from seven large clinical departments performed on 588 male and 412 female patients were evaluated. The age range was 17–98 years (median 66 years). The age range for male patients was 17–91 years (median 65 years), and the age range for female patients 18–98 years (median 69 years). After exclusion of 61 patients with incomplete medical records, 939 cases remained to evaluate.
The study setting was a tertiary referral hospital in which about thirty percent of all radiological examinations are of the chest according to yearly audits. All referrals were listed at the end of the day. The examinations were performed during a six-week period.
The outcome of chest radiography was classified as normal, incidental, or pathologic. Normal was defined as without incidental or pathologic findings in the parenchyma, pleurae, or hila. Incidental findings were defined as a chest examination showing findings deviating from normal but without need for medical treatment. Incidental findings included changes such as aortic calcifications, elongated thoracic aorta, minor pleural calcifications or scars, or mild chronic obstructive disease. Pathologic findings were those in need of medical treatment, such as pneumonic infiltrates, cardiac incompensation, pneumothorax, or rib fractures. At the time of the study electronic medical records had not been fully implemented, and medical records were available on paper and on microfilm. The referring physician’s reaction to the radiologic outcome (how the referring physician evaluated the report) was divided into three groups (highly expected results, moderately expected results, and unexpected results). Highly expected results were those where the clinician received confirmation of a clinical suspicion of pathology such as pneumonia or a normal radiography report on a routine study done for screening purposes. Moderately expected results were those where clinical suspicion was not very high but was confirmed, or another chest pathology than the suspicion given in the referral form was present to account for symptoms. Unexpected results were those where the radiologic findings were contrary to the clinical suspicion, such as normal chest radiography on a patient with clinical suspicion of pneumonia. The influence of the chest radiography examination on the patients’ treatment was divided into four groups: major influence, moderate influence, minor influence, and no influence. Major influence represented a radiology report that initiated or changed medical treatment. Moderate influence represented cases where the outcome of chest radiography confirmed the tentative clinical diagnosis, and treatment was started. Minor influence represented cases where radiology confirmed already diagnosed disease and induced no change in treatment. No influence represented cases where radiology did not influence treatment. All available medical records including daily notes, nurses’ records, summaries, and the request forms for chest radiography were analyzed. Primarily it was noted whether the medical records contained any written reference to the radiological examination, apart from the proper radiology report.
Statistical analysis was performed using StatView for Windows 4.57 (Abacus Concepts, Inc.). Descriptive statistics are presented as median and range. The significance of the results was calculated using Pearson’s chi-squared test, where a
Most requests for radiography (92.9%) came from the departments of internal medicine (
Radiologic outcome was pathologic in 500 cases (53.2%), showed incidental findings in 77 (8.2%), and was normal in 362 cases (38.6%). Regardless of radiologic findings, 71.6% of all studies had a clinically highly expected outcome (Table
Concordance between radiographic outcome and clinician’s expectations in 939 chest radiographs, grouped according to the chest radiography findings. Normal studies had a higher degree of expected outcome than pathologic studies.
Result | Highly expected | Moderately expected | Unexpected | Total |
---|---|---|---|---|
Normal | 291 (80.4%) | 64 (17.7%) | 7 (1.9%) | 362 (100.0%) |
Incidental | 64 (83.1%) | 8 (10.4%) | 5 (6.5%) | 77 (100.0%) |
Pathologic | 317 (63.4%) | 86 (17.2%) | 97 (19.4%) | 500 (100.0%) |
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Total | 672 (71.6%) | 158 (16.8%) | 109 (11.6%) | 939 (100.0%) |
Chest radiography had a major influence on treatment in 491 cases (52.3%), a moderate influence in 23.0%, a minor influence in 17.7%, and no influence in 7.0% (Table
Alteration or influence on treatment by 939 radiographic chest examinations, grouped according to chest radiographic outcome. Pathologic studies had the highest rate of influence on treatment choices.
Major | Moderate | Minor | No influence | Total | |
---|---|---|---|---|---|
Normal | 134 (37.0%) | 78 (21.5%) | 99 (27.3%) | 51 (14.1%) | 362 (100.0%) |
Incidental | 30 (39.0%) | 24 (31.2%) | 18 (23.4%) | 5 (6.5%) | 77 (100.0%) |
Pathologic | 327 (65.4%) | 114 (22.8%) | 49 (9.8%) | 10 (2.0%) | 500 (100.0%) |
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Total | 491 (52.3%) | 216 (23.0%) | 166 (17.7%) | 66 (7.0%) | 939 (100.0%) |
The radiographic outcome was highly expected in 672 cases (71.6%), moderately expected in 158 (16.8%), and unexpected in 109 cases (11.6%). Unexpected findings had a major influence on treatment in 76.1% (83 of 109 cases), somewhat more than that for moderately expected findings (Table
Alteration or influence on treatment by 939 chest radiography examinations, grouped according to the referring physicians’ anticipation of the chest radiography outcome. Unexpected chest radiography results influenced treatment to a higher degree than moderately or highly expected results.
Major | Moderate | Minor | No influence | Total | |
---|---|---|---|---|---|
Highly expected | 302 (44.9%) | 171 (25.4%) | 140 (20.8%) | 59 (8.8%) | 672 (100.0%) |
Moderately expected | 106 (67.1%) | 30 (19.0%) | 17 (10.8%) | 5 (3.2%) | 158 (100.0%) |
Unexpected | 83 (76.1%) | 15 (13.8%) | 9 (8.3%) | 2 (1.8%) | 109 (100.0%) |
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Total | 491 (52.3%) | 216 (23.0%) | 166 (17.7%) | 66 (7.0%) | 939 (100.0%) |
More than half of the radiological examinations were not referred to in the clinical records. Several were not even noticed. The lowest rate was noted for routine preoperative chest radiographs and radiography prior to coronary angiography. The highest annotation rate of the radiologic outcome in the clinical medical records, 58.7%, occurred when the radiologic outcome had a major influence on treatment (Table
Rate of annotations in the medical records about the outcome of chest radiography of 939 examinations, grouped according to influence of the chest radiography outcome on treatment. Cases with higher influence on treatment were to a higher degree remarked on in the medical records.
Annotation | No annotation | Total | |
---|---|---|---|
Major | 288 (58.7%) | 203 (41.3%) | 491 (100.0%) |
Moderate | 102 (47.2%) | 114 (52.8%) | 216 (100.0%) |
Minor | 23 (13.9%) | 143 (86.1%) | 166 (100.0%) |
No influence | 11 (16.7%) | 55 (83.3%) | 66 (100%) |
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Total | 424 (45.2%) | 515 (54.8%) | 939 (100.0%) |
Preoperative examinations or examinations performed before coronary angiography were studied separately. Their clinical influence was low. Totally 17.8% of the 157 examinations were judged to have had a major influence on treatment, 24.2% a medium influence, 38.2% a minor influence, and 19.7% no influence. Also the rate of annotation in the medical records was low. The results from preoperative chest examinations were noted in the medical records in 8.7% (11/126) and examinations before coronary angiography in 12.9% (4/31).
The main purpose of the current study was to evaluate the influence of daytime chest radiography on the clinical treatment of patients by a retrospective analysis of medical records but also to evaluate how the radiology reports were handled. The value of chest radiography in symptomatic emergency patients such as those encountered at night and during weekends is well known and not the subject of the current study. It might be argued that a retrospective study which is based on medical files and radiology reports would have less value than a prospective study. However, it has been shown that case notes do contain sufficient information to evaluate clinical performance retrospectively [
In the current study, moderately expected and unexpected outcomes were noted in 36.6% of the 500 pathologic examinations. Unexpected outcome was noted in 11.6% of all examinations. Chest radiographs demonstrating pathology had a higher rate of influence on the clinical treatment than radiographs demonstrating incidental or normal findings. This is consistent with the findings from other reports on hospital populations [
The clinicians’ reactions to the outcome of the radiologic examination was judged based on the notes in the medical records and also on our own clinical experience as the medical records sometimes were incomplete. In a high proportion of cases, we were unable to find any reference to the outcome of radiology in the medical records apart from the radiology report itself. In those cases we judged the clinical interest in the radiology examination to be very low and the examinations to a very large extent being routine without any clinical relevance like preoperative and pre coronary angiography examinations. The examinations which were most unexpected, and also influenced treatment most, were those with pathologic findings, and in those cases there was also a higher rate of annotation of the radiologic outcome in the medical records.
The influence on clinical treatment was judged to be high if there were medical notes about the radiologic outcome and about the consequences of the outcome. However, most medical records were not that eloquent, and in many cases we had to infer changes in treatment from changes in medication in the case notes, abstaining from planned operations, and so forth.
It was surprising that so many radiologic examinations went by unnoticed or without annotation. Totally, in more than half of the cases, there was no annotation in the medical records about the outcome of the study. The examinations where the outcome was pathologic or had an influence on the clinical treatment had a higher rate of annotation. Routine tests without influence on medical treatment should preferably be avoided, since they only take up valuable resources and disperse the information obtained from other tests for clinical reasons, an argumentation which is valid for all routine tests [
Routine preoperative examinations and examinations performed before coronary angiography had a very low rate of influence on treatment, even lower than that of the entire group of examinations with highly expected results, corresponding to results in previous studies on preoperative examinations [
It was, of course, impossible to exactly assess the clinical physicians’ rate of expectation of what radiology would yield. It was also difficult to assess the extent to which the radiology reports influenced diagnosis and treatment in the current study, since the evaluations have been made retrospectively on the data originally provided by the referring clinicians. It seems reasonable to suppose that some degree of misjudgment has been made, and we may have overestimated the clinical influence of the examinations but the main conclusions are probably valid.
A special problem has been the assessment of the influence of reports with no pathology. The value of the negative examination should, however, not be underestimated [
Examinations on patients without chest symptoms, such as preoperative examinations, examinations before coronary angiography, routine controls or followup, or purely administrative routine chest radiology had a very low rate of pathologic findings and thus in most cases had a highly expected outcome. They had a low clinical impact and should probably have been avoided. Also routine admission radiography may fall into this category [
In conclusion, there was a low rate of annotation about the chest radiology examinations in the medical records. Many chest radiology reports did influence decision making regarding diagnosis and treatment. The clinical utility of chest radiography thus appears fairly good, especially considering that the examination is rather inexpensive. The clinical utility is highest in patients with clinical symptoms and less in purely routine examinations on patients without symptoms.
The authors declare that they have no conflict of interests.
This work was supported by the Gothenburg Medical Society. The study was conducted at the Sahlgrenska University Hospital, Göteborg, Sweden.