Audit of chest X-rays in general practice--a case for local guidelines?

To investigate the use of the chest X-ray (CXR) in a typical urban practice with reference to the Royal College of Radiology (RCR) guidelines.

A retrospective review of all requests over a two-year period.

Urban general practice with 9,463 registered patients.

A total of 569 CXRs were performed in 482 patients. Thirty per cent of the CXRs were assessed as being "not indicated" and a significant percentage of requests did not come within the RCR guidelines. The guidelines advise a six weeks' delay following onset of chest wall pain prior to chest X-ray. We assessed the application of the rule in this patient group. A large percentage of those X-rayed were referred at less than the recommended six weeks' interval from time of presentation and the vast majority of CXRs were entirely normal. The "six weeks rule" was developed further in patients with cough, differentiating between simple and productive cough. Those with productive cough who were otherwise well had no significant findings in contrast to the unwell group where several abnormalities were noticed. Radiology-recommended follow-up films were further studied. Where the CXR was carried out after a time interval of less than three weeks, several showed incomplete resolution and a further film was required.

The RCR guidelines might be adapted to apply to those with simple cough or to those with productive cough who are otherwise well. This simple recommendation, in addition to the RCR guidelines, we feel would reduce the number of unnecessary CXRs performed in general practice.