Thorax

August 2015

FocusThorax

Ordering chest X-rays in Australian general practice

Volume 44, No.8, August 2015 Pages 537-539

Julie Gordon

Graeme C Miller

Ying Pan

Data from the BEACH program between 2012–14 were used to examine general practice encounters where chest X-rays were ordered. This included the most common problems associated with chest X-ray ordering and patient characteristics. Changes in ordering between 2004–05 and 2013–14 were also investigated. The rate of chest X-ray ordering between 2004–05 and 2013–14 decreased significantly. In 2012–14, chest X-rays were most often ordered in the management of acute bronchitis/bronchiolitis, cough and pneumonia. Pleurisy/pleural effusion had the highest likelihood of resulting in a chest X-ray order, followed by shortness of breath/dyspnoea and pneumonia.

Chest X-rays are the most frequently ordered imaging test in Australian general practice. They accounted for 8.3% of all imaging tests ordered by general practitioners (GPs) in 2013–14 at a rate of 0.6 orders per 100 problems managed.1

Little guidance is available regarding the ordering of chest X-rays, despite their relatively high frequency. Published guidelines relating to chest X-rays often focus on specific uses that are not relevant to GPs (eg for patients in intensive care units,2 pre-operative chest X-rays or chest trauma).3 Guidelines relating to particular medical conditions, including chronic dyspnoea and acute respiratory illnesses,3 may be of some use to GPs.

The aim of this study was to identify age and sex distributions of patients for whom chest X-rays were ordered, the most common problems for which chest X-rays were ordered and changes in the ordering rate of chest X-rays over the past decade.

Methods

This is a secondary analysis of data from the Bettering the Evaluation and Care of Health (BEACH) program. BEACH methods are described in detail elsewhere.4 Approximately 1000 randomly sampled, currently active, recognised GPs participate in BEACH every year. Each participant records the details of 100 encounters with consenting, unidentified patients on structured paper forms. It has been running continuously since 1998. The BEACH encounters analysed in this study were recorded between April 2012 and March 2014. Encounters were restricted to those that included a chest X-ray order. Additional analyses were performed on data collected between April 2004 and March 2014 to examine changes over time. Results were extrapolated to provide national estimates using the total number of Medicare GP consultation items claimed in the selected year. The method is detailed in the BEACH annual report.1

Results

There were 1872 chest X-rays ordered between April 2012 and March 2014 during BEACH encounters, at a rate of 0.60 per 100 problems managed (95% confidence interval [CI] = 0.56–0.64). Of these, 56.1% were ordered for female patients and 43.9% for males. More than two-thirds of chest X-rays were ordered for patients 45 years and older (70.8%), with 38.6% ordered for patients 65 years and older. Very few were ordered for children under the age of 15 years (6.0%).

Ordering rates for chest X-rays decreased significantly over the decade from 0.72 orders per 100 problems managed in 2004–05 (95% CI = 0.67–0.78) to 0.59 in 2013–14 (95% CI = 0.53–0.64).

There were 1922 problems associated with a chest X-ray order. Acute bronchitis/bronchiolitis (10.8%) was the problem for which chest X-rays were ordered most often (Table 1). This was followed by pneumonia (6.9%), asthma (4.5%) and chronic obstructive pulmonary disease (COPD; 4.2%). Symptoms, including cough (8.2%), chest pain (5.4%) and shortness of breath/dyspnoea (4.5%) were also common problems for which chest X-rays were ordered. Two percent of chest X-rays were ordered during general check-ups.

There was a high likelihood of chest X-rays being ordered during GP encounters at which pleurisy/pleural effusion was managed. More than one-third (34.4%) of these problems resulted in an order for a chest X-ray, whereas chest X-rays were ordered for 29.7% of all shortness of breath/dyspnoea problems. In contrast, The likelihood of a chest X-ray being ordered for acute bronchitis/bronchiolitis, in contrast, was low (5.3%).

Extrapolation of these estimates to all general practice encounters in Australia suggests there were 1,257,000 chest X-rays ordered each year between 2012–14. There were 140,000 ordered for the management of acute bronchitis/bronchiolitis and 106,000 in the management of cough. Ordering chest X-rays for pneumonia occurred at an estimated 89,000 encounters annually during that same period (Table 1).

Table 1. Most common problems associated with an order for a chest X-ray between 2012–14

Problem managed

Percent of total problems – chest X-ray combinations

(95% CI)

Percent of specified problems with a chest X-ray order

(95% CI)

Extrapolated average annual national estimate of encounters involving chest X-rays

Acute bronchitis/bronchiolitis

10.8

(9.3–12.4)

5.3

(4.3–6.1)

140,000

Cough

8.2

(7.0–9.4)

14.2

(12.2–16.3)

106,000

Pneumonia

6.9

(5.7–8.1)

26.1

(22.2–30.1)

89,000

Chest pain, NOS

5.3

(4.2–6.3)

14.9

(12.2–17.7)

68,000

Asthma

4.5

(3.5–5.6)

2.2

(1.6–2.7)

58,000

Shortness of breath/dyspnoea

4.4

(3.5–5.4)

29.7

(24.2–35.2)

57,000

Chronic obstructive pulmonary disease

4.2

(3.2–5.1)

4.4

(3.4–5.4)

54,000

Chest symptom/complaint

4.0

(3.1–4.9)

19.0

(15.2–22.8)

52,000

Heart failure

2.9

(2.1–3.7)

4.7

(3.4–6.0)

37,000

Upper respiratory tract infection

2.5

(1.7–3.4)

0.5

(0.3–0.7)

33,000

Fracture*

2.2

(1.6–2.9)

2.3

(1.6–2.9)

29,000

General check-up*

2.0

(1.3–2.8)

0.6

(0.4–0.9)

26,000

Respiratory disease, other

1.8

(1.2–2.4)

7.2

(4.9–9.5)

23,000

Pleurisy/pleural effusion

1.7

(1.1–2.3)

34.4

(24.2–44.5)

22,000

Respiratory infection, other

1.7

(1.0–2.3)

3.4

(2.2–4.7)

21,000

Subtotal

63.1

815,000

TOTAL

100.0

1,257,000

*Includes multiple ICPC-2 and/or ICPC-2 PLUS codes

The percentage of total contacts with the problem that generated an order for a chest X-ray

n = 1922; CI, confidence interval; NOS, not otherwise specified; ICPC-2, International Classification for Primary Care

Discussion

This study shows that one in 10 chest X-rays were ordered for the management of acute bronchitis/bronchiolitis, although only 5% of acute bronchitis/bronchiolitis problems resulted in a chest X-ray order. Similarly, chest X-ray orders for upper respiratory tract infections accounted for 2.5% of all chest X-ray orders, but chest X-rays were ordered for only 0.5% of upper respiratory tract infections managed. There are numerous factors to consider when ordering a chest X-ray for patients with acute respiratory illnesses. These include patient age and presence of physical signs (eg crackles or decreased breath sounds).3

Chest X-rays were ordered for one in eight cough problems. However, the Australian cough guidelines5 do not provide clear indications for ordering chest X-rays. The high likelihood of chest X-ray orders associated with dyspnoea was unsurprising as this is recommended in guidelines.3,6

Guidelines such as the Royal Australian College of General Practitioners’ Guidelines for preventive activities in general practice, 8th edition (the Red book)7 do not include chest X-rays in their recommendations for preventive activities.The relatively low rate of chest X-rays ordered as part of a general check-up suggests GPs are generally compliant with these guidelines.

A recent report from the BEACH program found a significant decrease in ordering of diagnostic radiology tests despite increased ordering of computed tomography (CT) scans, ultrasounds and magnetic resonance imaging (MRI).8 The decline in the number of chest X-rays ordered over the past decade reflects the overall decrease in diagnostic radiology ordering. However, the decrease in chest X-ray orders was not accompanied by an increase in chest CT scans (data not shown).

This paper provides an overview of chest X-ray ordering in general practice, and may provide background for other papers in this edition of Australian Family Physician.

Authors

Julie Gordon BAppSc (HIM) (Hons), PhD, Research Fellow, Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, NSW. julie.gordon@sydney.edu.au

Graeme Miller MBBS, PhD, FRACGP, Medical Director, Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, NSW

Ying Pan BMed MCH, Senior Research Analyst, Family Medicine Research Centre, Sydney School of Public Health, Sydney Medical School, University of Sydney, NSW

Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.

References

  1. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2013–14. General practice series no. 36. Sydney: Sydney University Press, 2014. Available at http://purl.library.usyd.edu.au/sup/9781743324219 [Accessed 11 May 2015].
  2. Amorosa JK, Bramwit MP, Mohammed TL, et al. ACR appropriateness criteria routine chest radiographs in intensive care unit patients. J Am Coll Radiol 2013;10:170–74.
  3. Government of Western Australia Department of Health. Diagnostic Imaging Pathways – Respiratory Pathways. Perth: Government of Western Australia Department of Health, 2015. Available at www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/respiratory [Accessed 3 March 2015].
  4. Britt H, Miller GC. The BEACH program update. Aust Fam Physician 2015;44:411–14.
  5. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian cough guidelines summary statement. Med J Aust 2010;192:265–71.
  6. BMJ Best Practice. Assessment of dyspnoea. London: BMJ, 2014. Available at http://bestpractice.bmj.com/best-practice/monograph/862/diagnosis.html [Accessed 27 February 2015].
  7. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 8th edn. Melbourne: RACGP, 2012.
  8. Britt H, Miller GC, Valenti L, et al. Evaluation of imaging ordering by general practitioners in Australia 2002–03 to 2011–12. General practice series no. 35. Sydney: Sydney University Press, 2014.

Acknowledgements

We wish to thank the general practitioners who participated for their generosity. During the data collection period of this study, the BEACH program was funded by the Australian Government Department of Health, AstraZeneca Pty Ltd (Australia), Novartis Pharmaceuticals Australia Pty Ltd, bioCSL (Australia) Pty Ltd, Merck Sharp & Dohme (Australia) Pty Ltd, Pfizer Australia Pty Ltd, Sanofi-Aventis Australia Pty Ltd, GlaxoSmithKline Australia Pty Ltd, National Prescribing Service Ltd; Janssen-Cilag Pty Ltd; Abbott Australasia Pty Ltd; Roche Products Pty Ltd; Bayer Australia Ltd; Wyeth Australia Pty Ltd; and the Australian Government Department of Veterans’ Affairs.

Correspondence afp@racgp.org.au

Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No

    

 

 

 

 

Competing Interests: 

Your comment is being submitted, please wait

 

Download citation in RIS format (EndNote, Zotero, RefMan, RefWorks)

Download citation in BIBTEX format (RefMan)

Download citation in REFER format (EndNote, Zotero, RefMan, RefWorks)

For more information see Wikipedia: Comparison of reference management software

Type

Focus