ARTICLE IN PRESS

Original Investigation

X-ray Use in Chest Imaging in

Emergency Department on the Basis
of Cost and Effectiveness
Erdem Fatihoglu, MD, Sonay Aydin, MD, Fatma Dilek Gokharman, MD, Bunyamin Ece, MD,
Pinar Nercis Kosar, Associate Professor

Rationale and Objectives: The increasing use of imaging in the emergency department (ED) services has become an important problem
on the basis of cost and unnecessary exposure to radiation. Radiographic examination of the chest has been reported to be per-
formed in 34.4% of ED visits, and chest computerized tomography (CCT) in 15.8%, whereas some patients receive both chest radiography
and CCT in the same visit. In the current study, it was aimed to establish instances of medical waste and unnecessary radiation ex-
posure and to show how the inclusion of radiologists in the ordering process would affect the amount of unnecessary imaging studies.
Materials and Methods: This retrospective study included 1012 ED patients who had both chest radiography and CCT during the
same visit at Ankara Training and Research Hospital between April 2015 and January 2016. The patients were divided into subgroups
of trauma and nontrauma. To detect unnecessary imaging examinations, data were analyzed according to the presence of additional
findings on CCT images and the recommendation of a radiologist for CCT imaging.
Results: In the trauma group, 77.1% (461/598) and in the nontrauma group, 80.4% (334/414) of patients could be treated without any
need for CCT. In the trauma group, the radiologist recommendation only, and in the nontrauma group, both the radiologist recommen-
dation and the age were determined to be able to predict the risk of having additional findings on CCT.
Conclusions: Considering only the age of the patient before ordering CCT could decrease the rate of unnecessary imaging. Including
radiologists into both the evaluation and the ordering processes may help to save resources and decrease exposure to ionizing radiation.
Key Words: Chest imaging; emergency department; cost; unnecessary; duplicating.
© 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

INTRODUCTION in more than 13% of cases (6), and some patients receive both
CXR and CCT in the same visit.

F
rom the beginning of the 20th century, imaging has
Unnecessary usage of chest imaging may expose patients
been a rapidly growing field of physician services (1).
to ionizing radiation and increase the potential cancer risk es-
Imaging studies are primarily performed in hospital out-
pecially in young adults and children, increase costs, and extend
patient facilities, private offices, hospital inpatient facilities, and
the time of stay in ED (4,7,8).
emergency departments (ED) (2). The increasing use of imaging
In this study, it was aimed to determine medical waste and
in ED services has attracted the attention of a significant number
unnecessary radiation exposure and also to provide some insight
of researchers. Various studies have suggested that this in-
into unnecessary chest imaging. It was also aimed to deter-
crease, especially in cases of computerized tomography (CT),
mine whether including radiologists in the ordering process
has higher costs but has not provided improved outcomes (3,4).
would decrease the amount of duplicating imaging studies.
The number of ED visits has also increased from 123.8
million in 2008 to 136.3 million in 2011. It has been re-
ported that radiographic examination of the chest is performed MATERIALS AND METHODS
in 34.4% of ED visits, and a chest computerized tomogra- Approval for the study was granted by the institutional ethics
phy (CCT) in 15.8% of visits (5). Chest radiography (CXR) review board. Informed consent of the patients for partici-
is applied at the ED visits of more than 70% of patients with pation was not required because of the design of the study.
acute cardiothoracic symptoms, CCT for the same indication A retrospective evaluation was made of ED patients at Ankara
Training and Research Hospital who were applied with both
Acad Radiol 2016; ■:■■–■■
CXR and CCT during the same visit between April 2015
From the Department of Radiology, Ankara Training and Research Hospital,
Ulucanlar Caddesi, 06340 Ankara, Turkey. Received January 31, 2016; revised and January 2016.
May 5, 2016; accepted May 9, 2016. Address correspondence to: S.A. e-mail: A total of 1203 patients were found to have undergone both
sonaydin89@hotmail.com
CXR and CCT during the same visit, but 191 patients were
© 2016 The Association of University Radiologists. Published by Elsevier Inc.
All rights reserved.
then excluded as 83 did not have optimal CXR studies for as-
http://dx.doi.org/10.1016/j.acra.2016.05.008 sessment and in the other 108, CCT was applied before CXR.

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FATIHOGLU ET AL Academic Radiology, Vol ■, No ■, ■■ 2016

Figure 1. Diagram showing the evaluation process of the study.

CXR examinations were performed with Samsung XGEO

GC80/GC80V series. The CT scanner available in our hos-
pital is GE Optima CT540, 16 slices, and CCT examinations
were obtained beginning from the thoracic inlet to the upper
abdomen. Both contrast-administered and noncontrast-
administered images were included in the study. In our ED
radiology department, contrast administration is used only for
diagnosis of pulmonary embolism and dissections. All images
were obtained from the Picture Archiving Communication
Systems of our hospital.
All the CXR and CCT images were reviewed by two ra-
diologists together. The radiologists, who had 25 years and
3 years of experience, were given very limited information
about the patients’ clinical condition. Reasons for presenta-
tion at ED were stated simply as “trauma” or “nontrauma,”
and the patients were accordingly divided into two groups.
The radiologists first examined the CXRs and recorded the
findings. They were asked to determine whether a further CCT
examination was needed, then the CCT images of the same
patient were examined by the radiologists. Chronic patholo-
gies or minor additional findings that were not considered able
to change the clinical approach were not accepted as addi-
tional findings. The CXR findings were checked against the Figure 2. Chest radiography (CXR) (a) and chest computerized to-
CT images, and any additional findings were recorded (Fig 1). mography (CCT) (b) images of a nontrauma patient. On CXR,
The patients were divided into two groups according to the pneumomediastinum (arrows) was detected and further CCT exam-
ination was recommended. There were no additional findings.
presence or absence of additional findings (Fig 2). Represen-
tative cases are shown in (Figures 2–5).
with the Mann-Whitney U test. Categorical data were stated
Statistical Analysis
as frequencies (n) and percentages (%) and were compared using
the Fisher exact or chi-square tests where appropriate. To
Statistical analyses were performed using SPSS Statistics soft- analyze the association of baseline and procedural factors on
ware (version 21.0; SPSS Inc., Chicago, Illinois, USA). additional findings, univariable logistic regression analysis was
Continuous parameters were stated as mean ± standard de- applied. When parameters were found to be univariably as-
viation, and skewed continuous parameters were evaluated sociated with the outcome and in a strong relationship with

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Academic Radiology, Vol ■, No ■, ■■ 2016
Figure 3. Chest radiography (CXR) (a) and chest computerized to-
mography (CCT) (b) images of a nontrauma patient. On CXR, there
was no pathologic finding. Further CCT examination was not rec-
ommended. On CCT images, infiltration (arrow) was present as an
additional finding.
some others, only the variables showing the strongest univariable
association with the outcome (P < 0.25) were included in the
stepwise multivariable logistic regression analysis (9). A two-
tailed value of P < 0.05 was considered statistically significant.
The institutional review board of our hospital approved the
current study. Informed consent of patients was not re-
quired (Fig 5).
RESULTS
Patients
The study included a total of 1012 patients (414 nontrauma,
598 trauma), comprising 350 (34.6%) women and 662 (65.4%)
men with a mean age of 45 ± 21.8 years (range, 1–92 years).
Additional findings were present on the CCT images of
217 (21.4%) patients. The distribution of additional findings
is shown in Table 1. Only one additional finding was deter-
mined in 173 (79.7%) cases and more than one additional
finding in 44 (20.3%) cases.
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X-RAY ON CHEST IN EMERGENCY DEPARTMENT
Figure 4. Chest radiography (CXR) (a) and chest computerized to-
mography (CCT) (b) images of a trauma patient. Pleural or extrapleural
thickening (arrow) was determined in the left middle zone. Further
CCT examination was recommended. The thickening was caused
by pleural hemorrhage and there was a displaced fracture of the
seventh rib, as an additional finding.
Trauma Versus Nontrauma
The mean age was determined as higher in the nontrauma
group than in the trauma group (51.7 ± 22.1 years, 40.4 ± 20.5
years respectively, P < 0.001). The most frequent additional
findings in the nontrauma group were consolidation (50%),
pulmonary embolism (31%), and pleural effusion (21.3%). In
the trauma group, the most common additional findings were
rib fracture (60.6%), lung contusion (24.8%), pleural effu-
sion (13.9%), and vertebra fracture (10.9%).
The number of CXR examinations with pathologic find-
ings was higher in the nontrauma group than in the trauma
group (41.5%, 13.4% respectively, P < 0.001). The radiolo-
gists recommended CCT examination to more patients in the
nontrauma group than in the trauma group (25.6%, 10.2%
respectively P < 0.001). The presence of additional findings
was similar in both groups (19.3%, 22.9% respectively,
P = 0.172). The number of patients with more than one ad-
ditional finding was higher in the trauma group (11.3% vs.
25.5%; respectively, P = 0.014).
3
FATIHOGLU ET AL
Figure 5. Chest radiography (CXR) (a) and chest computerized to-
mography (CCT) (b) images of a trauma patient. There was no
pathologic finding on CXR. Because of the patient’s age (89 years),
the radiologists recommended CCT examination. There was a chronic
compression fracture on the 10th thoracic vertebra. This was not ac-
cepted as an additional finding because of the chronic condition of
the pathology.
Presence of Additional Findings
The mean age of patients with additional findings on CCT
images was higher than those with no additional findings
(51.1 ± 22.0 years, 43.4 ± 21.5 years respectively, P < 0.001).
In patients with additional CT findings, the rate of abnor-
mal CXR examination was found to be higher (42.9%, 20%
respectively). It was seen that the CCT examination had been
recommended more to the patients with additional findings
(36.9%, 10.9% respectively, P < 0.001).
4
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Academic Radiology, Vol ■, No ■, ■■ 2016
TABLE 1. The Distribution of Additional Findings
Number
Additional Findings (Percentage)
Rib fracture 86 (39.6)
Consolidation 44 (20.3)
Contusion 36 (16,6)
Pleural effusion 36 (16,6)
Pulmonary embolism 25 (11,5)
Vertebral fracture 15 (6,9)
Pneumothorax/Hemothorax 14 (6,5)
Others (pericardial effusion, mediastinal 5 (2,3)
emphysema, dissection, mass lesions, small
airway disease, etc.)
Total 217 (21,4)
In the group with additional findings, there were more male
patients (71% men, 63.9% women, P = 0.054) and more from
the trauma than the nontrauma group (63.1% trauma, 58.0%
nontrauma, P = 0.172). These findings were not statistically
significant.
Regression Analysis
According to the results of the regression analysis applied to
the whole group, with an increase of 1 year in age, the pos-
sibility of additional findings on CCT increased 1.150 times.
The recommendation by the radiologists for a CCT exam-
ination increased the rate of determination of additional findings
4.145 times.
According to the regression analysis results obtained from
the trauma group, only the radiologist recommendation could
predict the risk of additional findings determined on CCT.
In the nontrauma group, both the radiologist recommenda-
tion and age could predict the risk of additional findings
determined on CCT (Table 2).
The radiologist recommendation for CCT was deter-
mined to be successful as a diagnostic tool in predicting the
presence of additional findings with a sensitivity of 36.9% and
a specificity of 89.1%.
DISCUSSION
Unlike the trends in other departments, the utilization of
imaging in the ED apparently continues to increase, with a
significant amount of that increase on the basis of CT and
XR (10). Multiple studies have shown that approximately
US$20 billion has been spent on unnecessary and duplicated
imaging studies (11,12). Studies in literature have predicted
that the elimination of unnecessary imaging could make an
annual saving of US$81 billion (13). Other than potential source
problems, unnecessary ED imaging increases exposure to ion-
izing radiation. CT scans constitute the largest source of medical
exposure to ionizing radiation in the United States. The uti-
lization of CT has increased from 52 CT scans per 1000 patients
Academic Radiology, Vol ■, No ■, ■■ 2016 X-RAY ON CHEST IN EMERGENCY DEPARTMENT

TABLE 2. Regression Analysis Results

Univariable Multivariable

%95C.I. %95C.I.
Variables OR Lower Upper P OR Lower Upper P
All population
Age 1,160 1,090 1,230 <0,001* 1,150 1,070 1,230 <0,001*
Radiologist recommendation (ref: not recommended) 4,752 3,334 6,774 <0,001* 4,145 2,282 7,529 <0,001*
Sex (ref**:female) 1,381 0,996 1,915 0,053 — — — —
CXR (ref:normal) 3,000 2,178 4,132 <0,001* — — — —
Trauma (ref: nontraumatic) 1,241 0,910 1,691 0,172 — — — —
Nagelkerke R2 = 0,253; P < 0,001*
Trauma group
Radiologist recommendation (ref: not recommended) 3,791 2,268 6,336 <0,001* 3,772 1,711 8,316 0,001*
Age 1,120 1,010 1,230 0,046 — — — —
Sex (ref:female) 1,506 0,903 2,512 0,117 — — — —
CXR (ref:normal) 2,381 1,448 3,915 0,001* — — — —
Nagelkerke R2 = 0,197; P < 0,001*
Nontrauma group
Age 1,240 1,140 1,340 <0,001* 1,180 1,080 1,290 <0,001*
Radiologist recommendation (ref: not recommended) 9,417 5,281 16,792 <0,001* 4,490 1,753 11,500 0,002*
Sex (ref:female) 1,249 0,813 1,917 0,310 — — — —
CXR (ref:normal) 6,348 3,859 10,443 <0,001* — — — —
Nagelkerke R2 = 0,285; P < 0,001*

CXR, chest radiography; OR, odds ratio; 95% C.I., 95% confidence interval.
Stepwise backward method was used in multivariable regression models.
* P value < 0,05 indicated statistical significance.
** Ref: reference.

in 1996 to 149 per 1000 in 2010 (6,14). Of all cancers in the
United States, 1.5%–2% may be caused by radiation from CT
scans (15), which makes the radiation exposure from unnec-
essary CT scans a serious problem. In the literature, one can
encounter multiple studies stating that radiation exposure re-
ceived from multiple CT scans can increase cancer risk
significantly, especially in pediatric population and young adults
(16). Although technological efforts still concentrate on de-
creasing the amount of radiation per CT scan, it is clear that
any decrease in the number of unnecessary CT scans would
be very helpful. The increasing number of CT scans in ED
has resulted in overcrowding. ED visits that include CT scans
have increased by 14.2% per year since 1995, and thus in 2007,
a CT scan was performed in almost 14% of all ED visits. In
addition, each ED visit that includes the application of ad-
vanced imaging takes more time (median length of visit: 253
minutes) than others (137 minutes) (6).
In 2011, 10.9% of patients presenting at ED had acute
cardiothoracic symptoms, such as chest pain, cough, and short-
ness of breath (5). These clinical findings require CXR and
CCT examinations. Thoracic injuries resulting from trauma
are an important cause of death accounting for approximate-
ly 25% of trauma-related deaths. Imaging, primarily CXR and
especially CCT, plays an indispensable role in the evalua-
tion and follow-up of blunt chest trauma (17). It can be
understood from literature that both traumatic and nontraumatic
emergency pathologies are generally examined with chest
imaging modalities containing ionizing radiation. There-
fore, the effective use of CXR and CCT becomes even more
important in respect of cost-effectiveness and the potential harm
of ionizing radiation.
In this study, the primary aim was to determine the extent
of unnecessary chest imaging, potential waste of resources, and
unnecessary exposure to ionizing radiation. It was also aimed
to show that involving radiologists in the ordering process might
decrease the rate of unnecessary imaging.
Various studies have yielded different results about the utility
of CCT in trauma patients. Two retrospective studies give
varying conclusions about the effectiveness of chest CT. The
first (n = 1337) concluded that chest CT findings were asso-
ciated with “minimal clinical consequences,” whereas the second
(n = 2435) claimed that older male patients with any abdom-
inal or extremity injury ought to have chest CT for occult
injuries (18,19). In a Swiss study of 93 patients, 50% had ad-
ditional findings on CCT, and in a study by Langdorf et al.
this rate was as high as 71% (17,20). In the current study, the
rate of additional findings in the trauma group was 22.9% which
is lower in comparison to most of the literature. This can be
explained by the relatively younger age of the current study
population with the median age of the trauma patients of
40.4 ± 20.5 years. Another reason might be the ordering trend,
as clinicians order CCT scans even for minor traumas. The
current study finding of correlation between the age and the
presence of additional findings is consistent with literature (19).

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FATIHOGLU ET AL
In the trauma patients, the radiologists considered 518 CXRs
to be normal, and according to the CCT results, 82% (527/518)
were actually normal with no additional findings. In 42%
(34/80) of the pathologic CXRs, there was sufficient infor-
mation to diagnose current pathologies, with no additional
findings on the CCT images. Thus, a qualified CXR, ex-
amined by a qualified radiologist, can demonstrate current
pathologies in 77.1% (461/598) of patients without any need
for CCT. It can be inferred from the data that unnecessary
CCT imaging entailed a cost of approximately 8500–9000 USD
and 1940–2305 millisievert (mSv) total X-ray dose.
In the emergency setting, thoracic imaging, primarily CXR,
plays an indispensable role in the diagnosis for patients pre-
senting with cardiothoracic symptoms. CXRs generally solve
common problems, such as pneumonia, but are not suffi-
cient for cases of pulmonary embolism and pleural effusion
(21). In the current study, the distribution for additional find-
ings on CCT images is similar to reports in literature. The
rate of occult consolidation found on CCT images was slightly
high, which can be considered to be the result of plurality
of consolidation cases in the total patients. In addition, most
of the consolidations were located in difficult sites, such as
retrocardiac, retrosternal areas, and lower zones, and the ra-
diologists only had posteroanterior CXR images. In the
nontrauma patients of the current study, the radiologists con-
sidered 242 CXRs to be normal, and the CCT results
confirmed that 86% (209/242) were actually normal. No ad-
ditional findings were present in 72.6% (125/172) of the
pathologic CXRs. Thus, 80.4% (334/414) of the nontrauma
patients could have been treated without using CCT. These
data show that unnecessary imaging entailed a cost of ap-
proximately 6500–7000 USD and 1600–1700 mSv total X-ray
dose.
When the regression analysis results were considered, it could
be concluded that radiologists are important in the interpre-
tation of chest CXRs, which is consistent with views in
literature (22).
This study has some limitations. First, there was insuffi-
cient information about the clinical conditions and laboratory
results of the patients, which may have had an effect on the
number of additional CCT examinations. In addition, the ra-
diologists eliminated some minor findings which were
considered unimportant for the clinical approach. The in-
clusion of clinicians in this elimination process might change
the results.
Information about the clinical outcomes was available for
253 (24.8%) patients only. Thus, the correlation between the
presence of additional findings and the clinical outcome could
not be evaluated in the current study.
CXRs of very poor quality (positioning problems, very low
or very high dose examinations, too many artifacts etc.) were
eliminated from the current study, which might have el-
evated the diagnostic performance of CXR examinations in
comparison to the literature.
CXRs can be difficult to evaluate, and as the use of CT
images has become more widespread, CXRs have come to
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Academic Radiology, Vol ■, No ■, ■■ 2016
be seen as less important. Therefore, radiologists have lost some
of their skills of CXR evaluation. As some pathologies may
be overlooked by inexperienced radiologists/clinicians, dif-
ferent rates can be found with different radiologists. In the
current study, two radiologists with different levels of expe-
rience evaluated the CXRs, but the data of each radiologist
were not examined separately. Further studies managed in that
way might clarify the effect of experience on the results.
In this study, the radiologists took as much time as nec-
essary to evaluate CXRs. However, in the normal working
conditions of a crowded ED when there is a need for a prompt
diagnosis, the results could be different.
CONCLUSION
According to the results of this study, a consideration of the
age of the patient when ordering CCT could decrease the
rate of unnecessary imaging. In addition, younger patients,
who have less additional findings on chest CT, are more vul-
nerable to the potential neoplastic effects of ionizing radiation.
So a consideration of age can also prevent these harmful effects.
To save resources and decrease exposure to ionizing radia-
tion, the inclusion of radiologists into both the evaluation and
the ordering processes would be of great benefit.
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