Postoperative portable chest radiographs: Optimum use in thoracic surgery

Purpose: Daily portable chest radiographs are routinely ordered in many institutions after thoracic surgery. Our purpose was to assess the efficacy and cost of this practice and to determine the optimum use of postoperative x-ray studies. Methods: A prospective review of all portable chest x-ray films after 100 consecutive elective thoracotomies (DRG 75) was conducted. Each x-ray study initiated a three-part survey. First, the surgeon listed whether the x-ray study was routine and the anticipated management had it not been available. The radiologist then interpreted and scored the x-ray study as follows: negative, expected findings; A, minor findings necessitating no intervention; B, minor findings necessitating intervention; or C, major findings necessitating intervention. Finally, the x-ray film and the interpretation were returned to the surgeon. Any interventions necessitated by the x-ray study were recorded. Results: In 6 months, 99 patients underwent 82 pulmonary resections and 18 other major procedures. In the postoperative period, 769 portable chest x-ray studies were ordered, median five per patient (range 2 to 49). Of these, 731 (95%) were routine and 38 (5%), nonroutine. Severity scores were as follows: negative in 106 (13.8%), A in 558 (72.5%), B in 59 (7.7%), and C in 46 (6.0%). X-ray findings altered management in 43 of 769 studies (5.6%): in 33 routine (4.5%), in 10 nonroutine (26.3%), in 13 A (2.3%), in 22 B (37.3%), and in 8 C (17.4%). Conclusions: These results demonstrate that routine daily portable chest x-ray studies have a minimal impact on management. It is, in fact, nonroutine x-ray studies that more often alter management. Had routine portable chest x-ray studies, which cost $114 each in our institution, been limited to one immediately after the operation, only 133 such studies (100 routine and 33 nonroutine) would have been needed in the care of these patients. Elimination of 636 (82.7%) x-ray studies reduces the cost of care by $725 per patient ($286,000 annually). For major thoracic procedures, it is safe, efficacious, and cost effective to eliminate routine postoperative portable chest x-ray studies and order nonroutine portable studies only when clinically indicated.