Unnecessary plain abdominal films and Royal College of Radiology Guidelines

Kamal K Mahawar, Alastair Todd and Pradip K Datta

Key Words: Plain abdominal film, abdominal pain, Royal College of Radiology guidelines

Abstract

Background and Purpose: Indiscriminate use of plain abdominal films (PAF) leads to waste of precious resource and unnecessary radiation exposure. In our hospital, every X ray request undergoes a strict scrutiny and all attempts are made to justify the need for film on a case-by-case basis. The purpose of this study was to assess the extent of misuse of PAF and adherence to Royal College of Radiology (RCR) guidelines in our hospital.

Methods

We reviewed records and films of all 54 patients who had a PAF done in the radiology department of our hospital from 1st January to 30th June 2003. Clinical and radiological findings were obtained from patient notes, radiology request forms, X ray films and the radiologists' reports.

Results

Five patients were excluded from study because of incomplete records. The mean age of patients was 56 years (Range 2-87). The type of radiograph requested was Kidney, Ureter and Bladder (KUB) in 23 patients and supine abdominal film in remaining 26. 35 (71%) of the 49 films had no significant findings but in only 8 (16%) did the film have any impact on the patient management. A renal calculus was seen in only 1 out of the 18 suspected cases. RCR guidelines were followed in only 14 (28%) patients.

Conclusion

Our study shows that a significant number of requested PAFs are unnecessary and do not contribute much to the patient management. Authors feel that just following RCR guidelines could significantly reduce number of unnecessary PAFs.

Introduction

Routine practices are being challenged and replaced on a daily basis in current times of evidence-based medicine and increasing cost awareness. Ordering a battery of investigations without any particular objective in mind is no longer acceptable. Though the usefulness of PAF in patients with various abdominal conditions has been questioned at times, it still remains an abused investigation 1-6. RCR guidelines 7 seem to have had little impact in this direction. In our hospital, a policy of selective ordering of abdominal films is followed and indiscriminate ordering by junior medical staff is strongly discouraged. Moreover, the radiographers have a responsibility to justify radiation exposure and do need to be convinced fully in every case before the X-ray is done. The purpose of this audit was to assess the extent to which unnecessary PAF was being ordered in our hospital and also to see if we were adhering to RCR guidelines.

Materials and Methods

We identified and retrieved records of all 54 patients who underwent an abdominal radiograph in the radiology department of our hospital over a 6-month period from 1st January 2003 to 30th June 2003. Five patients were excluded from the study because of incomplete records. Patient's notes and the X ray films were obtained from the medical and radiology records respectively and reviewed. Clinical details and provisional diagnosis were noted from the case notes and the X ray request forms. We then reviewed the films in their proper clinical context. Radiologist's impressions as noted in the report issued by the radiology department were also taken into account before making a final note. Finally the case notes were reviewed to find out whether the film led to any change in management plan. Final diagnosis, when clearly made, was noted from the case notes or letters.

Results

The mean age of patients in our study was 56 years (Range 2-87). Twenty-three out of 49 (47%) were females. Provisional diagnosis was either ureteric colic or intestinal obstruction in most cases (Table 1).

As the table 1 shows, PAF was also requested for a variety of other conditions; its utility in many of which is very much doubtful. Royal College of Radiology guidelines were adhered to in only 14 (28%) patients. Table 2 lists the findings on the PAF as reported by the radiologist and reviewed by us.

Thirty-five out of 49 (72%) films did not have any significant finding on the films. Five films (10%) showed colonic faecal loading and other 5 (10%) showed only mild dilatation of the bowel loops. Out of 16 patients suspected to have intestinal obstruction, only 2 showed significant bowel loop dilatation on the abdominal film. Only 2(4%) films showed urinary calculi, one each in the kidney and the bladder. A definite final diagnosis was found in notes in only 24 (49%) cases. No final diagnosis could be made in the remaining patients emphasizing the difficulties in establishing a diagnosis in patients with abdominal pain. Overall PAF was found to contribute to management decisions in only 8 patients (16%).

Discussion

A formal diagnosis could only be made in this study in less than half of the patients at the time of discharge taking in account all the investigative modalities and surgery underscoring the fact that abdominal pain can be a difficult condition to diagnose. Frustrated by inability to reach a diagnosis, one may resort to PAF just in case it gave any clue. PAF however falls far short of being a useful tool in the diagnosis. In most cases (72%) there was no significant finding on the film taking into account the radiologists' observations. Other investigations like ultrasound and computed tomography, which may be more useful, require expertise, specific equipment, are expensive and may not be available at all times. Though these investigations can be extremely useful in allowing one to make a confident diagnosis or exclude suspected pathologies, there is usually some delay before they can be carried out. Under such circumstances one may feel more inclined to resort to PAF which is more easily and universally available. However few of these films contribute to management and clinicians need to realize that PAF is not a solution to the difficulties in diagnosing abdominal conditions.

After maximally stretching its benefits, PAF was found to be of some use in management decisions in only 16% patients in this study. This figure includes any significant negative finding, which could have helped in decision-making. It is only slightly better compared to 7% reported in another such study. 4 There was a poor adherence (28%) to RCR guidelines in our study. Others have made similar observation 4,8. It has been previously argued 8 that most abdominal films are ordered by junior medical staff, who may at times be under pressure to fully work the patient up. Adherence to RCR guidelines would provide junior doctors with clear-cut guidelines on which to base decisions.

Indiscriminate ordering of X rays not only leads to increased health care costs and unnecessary radiation but also promotes unscientific and illogical thinking. Junior doctors should be made more aware of relatively low value of PAFs during their teaching sessions at the time of their induction and at other appropriate educational events. Regular re-emphasis of the message that PAF is not required in the routine work up for every patient with abdominal pain from senior clinicians may convince junior doctors more effectively. Alternatively, posting readymade reference lists on doctors' notice boards or tying RCR booklet to the notes trolley could also help in improving awareness. We have identified a clear need in our hospital to promote the guidelines, eliminate wastage of precious resources and promote a more evidence based, and scientific approach. A similar audit would need to be conducted after about 6-12 months of making these efforts to assess changes in practice.

Conclusion

Our study shows that abdominal files are ordered unnecessarily in our hospital and guidelines are not followed. Clinicians need to have clear objectives in their mind before asking for a PAF. There is no such request as a "routine PAF" and the major limitation of PAF in diagnosing abdominal conditions must be realized. RCR guidelines are available and surgeons need to be made aware of these and should follow their recommendations in most cases.

Reference

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