1. Cost-Conscious Care Presentation Follow-up Chest X-Ray in Patients Admitted for Community Acquired Pneumonia Huy Tran, PGY-2 12/12/2013

2. Objectives Identify standard of care for appropriate use of follow-up chest X-Ray (CXR) in patient admitted for Community Acquired Pneumonia (CAP) Identify standard of care for appropriate use of follow-up chest X-Ray (CXR) in patient admitted for Community Acquired Pneumonia (CAP) Identify cost of inappropriate ordering follow- up CXR Identify cost of inappropriate ordering follow- up CXR

3. Introduction CXR is consistently the most commonly ordered radiologic imaging study in inpatient setting. CXR is consistently the most commonly ordered radiologic imaging study in inpatient setting. Pneumonia is the number 2 leading indication for ordering 1 view CXR in inpatient setting Pneumonia is the number 2 leading indication for ordering 1 view CXR in inpatient setting Current standard of care requires ordering CXR to establish radiologic evidence for any patient being admitted for suspected pneumonia. The presence of an infiltrate on plain chest radiograph is considered the gold standard for diagnosing pneumonia Current standard of care requires ordering CXR to establish radiologic evidence for any patient being admitted for suspected pneumonia. The presence of an infiltrate on plain chest radiograph is considered the gold standard for diagnosing pneumonia For hospitalized patients with suspected pneumonia and a negative chest radiograph, the 2007 Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS) consensus guidelines consider it reasonable to initiate empiric presumptive antibiotic therapy and repeat the chest radiograph in 24 to 48 hours For hospitalized patients with suspected pneumonia and a negative chest radiograph, the 2007 Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS) consensus guidelines consider it reasonable to initiate empiric presumptive antibiotic therapy and repeat the chest radiograph in 24 to 48 hours CXR is not cheap: current price range from $50 for insured patients to $200 for uninsured patients CXR is not cheap: current price range from $50 for insured patients to $200 for uninsured patients

4. Follow-up CXR: Yay or Nay? Current standard of care: the chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP. Current standard of care: the chest radiograph need not be repeated prior to hospital discharge in those who have made a satisfactory clinical recovery from CAP. 2007 IDSA/ATS consensus guidelines showed a change from previous guidelines: no recommendation for routine follow-up chest X-rays at about 6 weeks after episodes of community- acquired pneumonia, presumably to screen for malignancy after an acute infiltrate has cleared. Instead, this practice is only suggested for patients with persistent symptoms or those “at higher risk of underlying malignancy (especially smokers and those aged >50 years) 2007 IDSA/ATS consensus guidelines showed a change from previous guidelines: no recommendation for routine follow-up chest X-rays at about 6 weeks after episodes of community- acquired pneumonia, presumably to screen for malignancy after an acute infiltrate has cleared. Instead, this practice is only suggested for patients with persistent symptoms or those “at higher risk of underlying malignancy (especially smokers and those aged >50 years)

5. Method Cross sectional study, chart review Cross sectional study, chart review Inclusion criteria: all patients admitted to inpatient medicine service with admitting diagnosis of CAP confirmed on initial CXR in a 7 days period. Inclusion criteria: all patients admitted to inpatient medicine service with admitting diagnosis of CAP confirmed on initial CXR in a 7 days period. Exclusion criteria: CXR ordered with indication of suspected new onset aspiration or healthcare associated pneumonia, new onset chest pain or palpitation, persistent respiratory distress after 24-48hr of treatment, patient with concurrent moderate to severe COPD or CHF, history of pulmonary fibrosis, moderate to severe pulmonary effusion, dysphagia, malignancy, line or tube placement, poor image quality, ICU admission Exclusion criteria: CXR ordered with indication of suspected new onset aspiration or healthcare associated pneumonia, new onset chest pain or palpitation, persistent respiratory distress after 24-48hr of treatment, patient with concurrent moderate to severe COPD or CHF, history of pulmonary fibrosis, moderate to severe pulmonary effusion, dysphagia, malignancy, line or tube placement, poor image quality, ICU admission Identify number of routine follow-up CXR ordered prior to discharge. Identify number of routine follow-up CXR ordered prior to discharge. Estimate cost of inappropriate follow-up CXR ordering Estimate cost of inappropriate follow-up CXR ordering

6. Results 31 patients admitted to inpatient medicine service with confirmed diagnosis of CAP based on clinical and radiologic evidence within a 7 days period. 31 patients admitted to inpatient medicine service with confirmed diagnosis of CAP based on clinical and radiologic evidence within a 7 days period. 6 patients (19%) found to have follow-up CXR prior to discharge with indications other than those in the exclusion criteria. Of those 6 patients, a total of 7 CXR were ordered and obtained. 6 patients (19%) found to have follow-up CXR prior to discharge with indications other than those in the exclusion criteria. Of those 6 patients, a total of 7 CXR were ordered and obtained. Using the average cost of $100/1 view CXR, the total cost of inappropriate follow-up CXR ordering was $700 Using the average cost of $100/1 view CXR, the total cost of inappropriate follow-up CXR ordering was $700 Potential saving of $2800/month or $33,600/year for patients on medicine service Potential saving of $2800/month or $33,600/year for patients on medicine service

7. Conclusions Ordering CXR for the majority of patients (81%) admitted for CAP meet the current standard of care/guidelines Ordering CXR for the majority of patients (81%) admitted for CAP meet the current standard of care/guidelines Estimate cost of inappropriate follow-up CXR ordering is $2800/month or $33,600/year for patients on medicine service Estimate cost of inappropriate follow-up CXR ordering is $2800/month or $33,600/year for patients on medicine service Confounders: Confounders: Small sample size Small sample size Patients limited to medicine service, therefore limiting generalization to other services Patients limited to medicine service, therefore limiting generalization to other services 3/31 patients had follow-up CXR but indication was documented as other and there was no further documentation so those were excluded. Result of chart review depends on quality of documentation. 3/31 patients had follow-up CXR but indication was documented as other and there was no further documentation so those were excluded. Result of chart review depends on quality of documentation.

8. References Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community- acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community- acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27. Lim WS, George RC, et al. Guideline for the management of community acquired pneumonia in adult. Thorax. 2009; 64: Suppl 105-13. Lim WS, George RC, et al. Guideline for the management of community acquired pneumonia in adult. Thorax. 2009; 64: Suppl 105-13.