Diagnostic Imaging: Appropriate and Safe Use
Am Fam Physician. 2021 Jan 1;103(1):42-50.
Published online November 23, 2020.
Author disclosure: No relevant financial affiliations.
The use of diagnostic radiography has doubled in the past two decades. Image Gently (children) and Image Wisely (adults) are multidisciplinary initiatives that seek to reduce radiation exposure by eliminating unnecessary procedures and offering best practices. Patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 may have increased risk of nephropathy when exposed to iodinated contrast media and increased risk of nephrogenic systemic fibrosis when exposed to gadolinium-based contrast agents. American College of Radiology Appropriateness Criteria can help guide specific diagnostic imaging choices. Noncontrast head computed tomography is the first-line modality when a stroke is suspected. Magnetic resonance imaging stroke protocols and computed tomography perfusion scans can augment evaluation and potentially expand pharmacologic and endovascular therapy timeframes. Imaging should be avoided in patients with uncomplicated headache syndromes unless the history or physical examination reveals red flag features. Cardiac computed tomography angiography, stress echocardiography, and myocardial perfusion scintigraphy (nuclear stress test) are appropriate for patients with chest pain and low to intermediate cardiovascular risk and have comparable sensitivity and specificity. Computed tomography pulmonary angiography is the preferred test for high-risk patients or those with a positive d-dimer test result, and ventilation-perfusion scintigraphy is reserved for patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2 or a known contrast allergy. Computed tomography with intravenous contrast is preferred for evaluating adults with suspected appendicitis; however, ultrasonography should precede computed tomography in children, and definitive treatment should be initiated if positive. Ultrasonography is the first-line modality for assessing right upper quadrant pain suggestive of biliary disease. Mass size and patient age dictate surveillance recommendations for adnexal masses. Imaging should not be performed for acute (less than six weeks) low back pain unless red flag features are found on patient history. Ultrasonography should be used for the evaluation of suspicious thyroid nodules identified incidentally on computed tomography.
Estimates suggest that 30% of all U.S. health expenditures are a result of waste, with approximately $100 billion lost on overtreatment and low-value care; inappropriate radiography is a major component.1 The use of advanced imaging, including computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography, and nuclear medicine, has doubled in a 16-year period, accounting for 11% of allowed Medicare charges in 2018.2,3 Awareness of risks, benefits, and recommendations related to radiography enhances shared decision-making and reduces unnecessary testing.2,4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
Follow reduced radiation protocols from the Image Wisely (adults) and Image Gently (children) initiatives, and use American College of Radiology Appropriateness Criteria when making diagnostic imaging decisions.8–16
Expert opinion and longitudinal cohort studies
Large retrospective propensity-matched studies demonstrate no significant effect; expert opinion and consensus guidelines still encourage hydration in these patients
Expert opinion and consensus guidelines
Expert opinion and consensus guidelines
A clinical probability assessment tool should be used to determine pretest probability before performing imaging in patients with suspected pulmonary embolism. The Pulmonary Embolism Rule-out Criteria or d-dimer testing can be used to avoid unnecessary computed tomography pulmonary angiography in some low- or intermediate-risk patients.57–60
Expert opinion and well-designed randomized clinical trials with disease-oriented outcomes
Large meta-analysis of 20 trials with disease-oriented outcomes; expert opinion
Numerous randomized clinical trials and systematic reviews and meta-analyses
eGFR = estimated glo
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