In ACR–SPR–STR PRACTICE PARAMETER FOR THE PERFORMANCE OF CHEST RADIOGRAPHY (a practice guideline from the American College of Radiology, the Pediatric Society for Radiology and the Society of Thoracic Radiology) 2017 revision, in the Section of Indications and Contraindications (page 2 or 9); indication number 5 states:
“Preoperative radiographic evaluation when cardiac or respiratory symptoms are present when there is a significant potential for thoracic pathology that may influence anesthesia or the surgical result or lead to increased perioperative morbidity or mortality. Routine preoperative chest x-rays are not appropriate ."
Also, under Section V - Specifications of the Examination, the language includes:
"The written or electronic request for chest radiography should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination."
In American College of Radiology ACR Appropriateness Criteria; Routine Chest Radiography (2000-updated 2015); in the section Summary of Recommendations:
Summary of Recommendations
- Available evidence does not support the broad performance of routine chest radiography. Despite the frequent demonstration of abnormalities, routine chest radiographs uncommonly add clinically significant information that would not have been predicted by a reliable history and physical examination.
- In the case of the preoperative chest radiograph, evidence suggests that increased management value may accompany advanced patient age (especially >70 years) and certain other patient- and procedure-related risk factors (eg, history of cardiopulmonary disease, unreliable history and physical examination, high-risk surgery); however, the ability of a preoperative chest radiograph to forecast postoperative pulmonary complications is low.
- The decision to perform a chest radiograph in the preoperative, preintervention, hospital admission, and asymptomatic outpatient settings should principally derive from a need to investigate a clinical suspicion for acute or unstable chronic cardiopulmonary disease that could influence patient care. Selective ordering is recommended, including in patients of advanced age or otherwise at increased risk.
- Routine chest radiography is not definitively indicated in uncomplicated hypertension. There may be value in patients with moderate to severe hypertension and potential aortic coarctation or cardiogenic edema, in addition to patients with overt cardiopulmonary signs or symptoms.
- The anticipated value from ordering a chest radiograph should be weighed against adverse effects, including radiation exposure, procedural delay, anxiety, and potential morbidity from the investigation of incidental findings."
In an FDA publication; White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging, (updated 2-23-2017) there is discussion regarding types of imaging, concerns about radiation exposure and types of unnecessary exposure the white paper states:
“3. Unnecessary Radiation Exposure”
“Because CT, fluoroscopy, and nuclear medicine require the use of radiation, some level of radiation exposure is inherent in these types of procedures. Nevertheless, when these procedures are conducted appropriately, the medical benefits they can provide generally outweigh the risks.”
“However, if proper precautions are not taken, patients may be exposed to radiation without clinical need or benefit. Unnecessary radiation exposure may result from the use of a radiation dose above what is optimal to meet the clinical need in a given procedure. To a point, using a higher radiation dose can produce a higher-resolution image. If the dose is too low, the quality of the resulting image may be poor, and, as a result, a physician may not be able to make an accurate clinical determination. An optimal radiation dose is one that is as low as reasonably achievable while maintaining sufficient image quality to meet the clinical need.”
“Unnecessary radiation exposure may also result from the performance of a particular medical imaging procedure when it is not medically justified given a patient’s signs and symptoms, or when an alternative might be preferable given a patient’s lifetime history of radiation exposure.”
“There is broad agreement that steps should be taken to reduce unnecessary exposure to radiation”
Further on, under Issues Related to Decision Making: “In some cases, ordering physicians may lack or be unaware of recommended criteria to guide their decisions about whether or not a particular imaging procedure is medically efficacious. As a result, they may order imaging procedures without sufficient justification and unnecessarily expose patients to radiation. Various professional organizations, including American College of Radiology (ACR) and the American College of Cardiology (ACC), have developed and are working to disseminate imaging referral criteria, called “appropriateness criteria” or “appropriate use criteria,” associated with a number of medical conditions.18 However, criteria for appropriate ordering of medical imaging exams have not yet been broadly adopted by the practicing medical community.”
In a document entitled Choosing Wisely (a collaboration of the American Board of Internal Medicine, the American College of Radiology and Consumer Reports), a 2012 publication for patients and physicians-with Subtitle Chest X-Rays Before Surgery-When You Need One and When You Don’t; the language states:
“A chest X-ray usually doesn’t help."
“Many people are given a chest X-ray to “clear” them before surgery. Some hospitals require a chest X-ray for almost every patient. But, if you do not have symptoms of heart or lung disease, and your risk is low, an X-ray probably will not help. It is not likely to show a serious problem that would change your treatment plan.”
“A chest X-ray does not help the surgeon or the anesthesiologist manage your care. Most of the time, a careful medical history and physical exam are all you need.”
- In the Annals of the Royal College of Medicine, v.92(8); 2010 Nov. in an article entitled: Erect Chest Radiography in the Setting of the Acute Abdomen: Essential tool or an unnecessary waste of resources?, the authors state as their conclusion:
- “The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.”
Searching the National Library of Medicine, there was no supporting literature regarding or suggesting chest radiographs in the setting of common headaches, pain, unspecified urinary tract infections, lower back pain, trauma unrelated to the thorax or upper abdomen or unspecified conditions such a “general signs and symptoms”.
Although frequency of radiographs is not part of this local coverage determination, recent articles in the past 2 years are questioning the high frequency of repeat radiographs in the ICU, post certain procedures, and on ventilator patients.