Dec 162018

More than 60% of patients receiving mechanical ventilation have continued to receive daily chest x-rays since the publication of guidelines recommending against the practice. The findings came from a database review of hundreds of thousands of patients and were published in JAMA Network Open.

The American College of Radiology once recommended daily chest films in ventilated patients, but stopped endorsing the practice in 2008 (especially in stable patients), after multiple studies suggested daily chest x-rays did not improve outcomes. In 2011 and then in 2014, the ACR strengthened its disapproval to state that daily chest films were "usually not appropriate" in ICU patients without a change in clinical status.

Also in 2014, the major critical care professional societies together endorsed a Choosing Wisely statement advising against daily chest films and other daily routine tests like labs.

Most clinicians haven't changed practice in response. Daily chest x-rays declined slightly 2008 to 2014, but more than half of mechanically ventilated patients in 2014 still got daily chest films. Three-quarters of hospitals got daily chest films on at least half their mechanically ventilated patients.

Vented patients getting daily chest x-rays were more likely to be:

  • In the Northeast U.S. (compared to the Midwest)
  • White
  • Privately insured
  • Admitted for surgery
  • Diagnosed with a cardiovascular problem

The researchers estimated that more than 2 million chest films could be avoided, saving almost $150 million annually, if the hospitals with the highest chest x-ray rates brought their use down to that of the lowest quartile.

The reasons for the "over-use" of chest radiography weren't clear from the study, but it seems likely that physicians don't give these particular guidelines much weight, or are unaware of them entirely.

Chest x-rays carry little risk to the patient, and in communities where daily films continue to be considered the standard of care, a physician who deviates from the norm risks the perception of substandard care if random chance brings an important clinical event on a day a chest film was skipped.

Source: JAMA Open Network

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Daily chest X-rays the norm in ventilated patients, despite guidelines