Routine Chest X-Ray Found to Have Little Medical Value
Routinely taking chest X-rays of hospital patients, even when they show no symptoms of chest disease, has little medical value and adds as much as $1.5 billion to the cost of health care nationwide, a new study by physicians at the Long Beach Veterans Administration Medical Center has concluded.
The study, reported in today’s issue of the New England Journal of Medicine, was published on the heels of a year-old recommendation by the Food and Drug Administration that chest films not be ordered solely because of hospital admission. The Long Beach researchers said Wednesday that they expect their study will be used as ammunition to curtail the long-standing practice.
Their report noted that about 52 million chest films are taken annually in the United States, making the procedure the most frequently conducted of all X-ray examinations. About 30 million of them were for purposes that yielded little medical information that could not be gleaned from clinical histories or by other means, the researchers said.
The practice of ordering routine chest films gained popularity after World War II. Studies at that time showed that by taking the film as part of the hospital admission procedure, doctors could detect twice as many cases of tuberculosis as were detected when the X-rays were taken during mass screening programs in the community.
Today the threat of tuberculosis has greatly diminished and communitywide screenings are rare.
Later, doctors used chest films to screen for lung cancer, hoping that they would be able to detect cases early and improve the cure rate. That approach failed to improve the cure rate, however, and the American Cancer Society no longer recommends chest X-rays for that purpose.
Nevertheless, said Dr. F. Allan Hubbell and Dr. Sheldon Greenfield, principal authors of the study, doctors in most U.S. hospitals follow the practice, in part because of fears of a malpractice suit.
Bylaws of some hospitals require that patients have chest X-rays upon admission, Hubbell said in a telephone interview. Both he and Greenfield said, however, that they expect such requirements to change, in part because recent changes in state, federal and private reimbursement methods give hospitals the incentive to eliminate unnecessary tests.
In their study, the researchers looked at the records of 491 patients admitted to the Long Beach VA hospital’s internal medicine service during a 10-week period in 1982. Of these, 294--or 60%--had chest X-rays even though their doctors had no medical reason for expecting to find something wrong.
Although 106 of the 294 had abnormal X-rays, the conditions were already known to exist in nearly all cases, and the X-ray findings resulted in changes in treatment for only 12. In 11 of the 12, the researchers said, the information provided by the X-ray would have been detected by other means during the hospital stay.
High-Risk Patients In the 12th patient, the finding--lung cancer--probably would not have been detected otherwise. But, the researchers said, detecting the cancer did not affect the result. The patient died of the disease.
Because the study concluded that the effect on patient care was very small even in a VA hospital, whose patients are generally middle-aged or older and thus considered to be at high risk for chest diseases, the researchers concluded that it is unlikely that the average American patient benefits by routine chest screening.
Hubbell is an assistant professor of medicine at the University of California, Irvine, and Greenfield is a professor at the UCLA School of Public Health.
