Cost-Conscious Care Presentation
Follow-up Chest X-Ray in Patients
Admitted for Community Acquired
Pneumonia
Huy Tran, PGY-2
12/12/2013
Objectives
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Identify standard of care for appropriate use of
follow-up chest X-Ray (CXR) in patient
admitted for Community Acquired Pneumonia
(CAP)
Identify cost of inappropriate ordering followup CXR
Introduction
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CXR is consistently the most commonly ordered radiologic imaging
study in inpatient setting.
Pneumonia is the number 2 leading indication for ordering 1 view
CXR in inpatient setting
Current standard of care requires ordering CXR to establish
radiologic evidence for any patient being admitted for suspected
pneumonia. The presence of an infiltrate on plain chest radiograph
is considered the gold standard for diagnosing pneumonia
For hospitalized patients with suspected pneumonia and a negative
chest radiograph, the 2007 Infectious Diseases Society of America
and the American Thoracic Society (IDSA/ATS) consensus
guidelines consider it reasonable to initiate empiric presumptive
antibiotic therapy and repeat the chest radiograph in 24 to 48 hours
CXR is not cheap: current price range from $50 for insured patients
to $200 for uninsured patients
Follow-up CXR: Yay or Nay?
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Current standard of care: the chest radiograph need not be
repeated prior to hospital discharge in those who have made a
satisfactory clinical recovery from CAP.
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2007 IDSA/ATS consensus guidelines showed a change from
previous guidelines: no recommendation for routine follow-up
chest X-rays at about 6 weeks after episodes of communityacquired pneumonia, presumably to screen for malignancy after
an acute infiltrate has cleared. Instead, this practice is only
suggested for patients with persistent symptoms or those “at
higher risk of underlying malignancy (especially smokers and
those aged >50 years)
Method
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Cross sectional study, chart review
Inclusion criteria: all patients admitted to inpatient medicine
service with admitting diagnosis of CAP confirmed on initial
CXR in a 7 days period.
Exclusion criteria: CXR ordered with indication of suspected
new onset aspiration or healthcare associated pneumonia, new
onset chest pain or palpitation, persistent respiratory distress
after 24-48hr of treatment, patient with concurrent moderate to
severe COPD or CHF, history of pulmonary fibrosis, moderate
to severe pulmonary effusion, dysphagia, malignancy, line or
tube placement, poor image quality, ICU admission
Identify number of routine follow-up CXR ordered prior to
discharge.
Estimate cost of inappropriate follow-up CXR ordering
Results
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31 patients admitted to inpatient medicine service with
confirmed diagnosis of CAP based on clinical and
radiologic evidence within a 7 days period.
6 patients (19%) found to have follow-up CXR prior to
discharge with indications other than those in the
exclusion criteria. Of those 6 patients, a total of 7 CXR
were ordered and obtained.
Using the average cost of $100/1 view CXR, the total
cost of inappropriate follow-up CXR ordering was $700
Potential saving of $2800/month or $33,600/year for
patients on medicine service
Conclusions
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Ordering CXR for the majority of patients (81%)
admitted for CAP meet the current standard of
care/guidelines
Estimate cost of inappropriate follow-up CXR ordering
is $2800/month or $33,600/year for patients on
medicine service
Confounders:
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Small sample size
Patients limited to medicine service, therefore limiting
generalization to other services
3/31 patients had follow-up CXR but indication was
documented as other and there was no further
documentation so those were excluded. Result of chart
review depends on quality of documentation.
References
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Mandell LA, Wunderink RG, Anzueto A, et al.
Infectious Diseases Society of
America/American Thoracic Society consensus
guidelines on the management of communityacquired pneumonia in adults. Clin Infect Dis
2007; 44 Suppl 2:S27.
Lim WS, George RC, et al. Guideline for the
management of community acquired pneumonia
in adult. Thorax. 2009; 64: Suppl 105-13.