Assessment of Chest X-Ray Utilization for the Evaluation of Non-Traumatic Chest Pain in an Academic Emergency Department

Background: Overutilization of chest X-rays (CXR) is costly, inefficient and results in increased radiation exposure. Several studies have proposed clinical decision rules (CDR) for chest X-ray utilization in non-traumatic chest pain patients presenting to the Emergency Department (ED). However, CDRs are often not one size fits all and may differ based on population variability. The purpose of this study is to 1) Evaluate CXR utilization among ED patients suspected of acute coronary syndrome (ACS) presenting with non-traumatic chest pain and 2) Assess for factors associated with an abnormal CXR in our patient population using criteria from previously developed CDRs. Methods: We identified 14 clinical criteria from previously derived CDRs that may be predictive of an abnormal CXR. We retrospectively identified 500 patients over age 18 who presented with non-traumatic chest pain between January 2016 and December 2017. Charts were screened for 1) Whether a CXR was performed, 2) CXR results, and 3) The presence of any of the 14 clinical criteria. Results: 487 (97%) non-traumatic chest pain patients had a CXR performed. 266 (54.6%) patients with zero of the 14 risk factors had a CXR performed. Of those patients, 11 (4.1%) had an abnormality on CXR, 3 (1.1%) of which led to a change in clinical management. Absence of all 14 clinical criteria resulted in a negative predictive value (NPV) of 99%. Further analysis revealed that 9 of the 14 risk factors could be removed in our population with no change in the NPV. Conclusion: The use of the 6 risk factors from the previously developed CDRs would have reduced CXR utilization by 55% with a NPV of 99%. No single CDR perfectly fit our ED population thus demonstrating variability and need to tailor criteria to each patient population.