A Protocol for Selecting Patients with Injured Extremities Who Need X-Rays

TLDR

Excessive radiography remains a concern, as even the best protocols cannot eliminate all negative x‑ray studies. The study developed and prospectively tested a protocol to select injured extremity patients who need x‑ray examination, aiming to curb excessive radiography while ensuring safety and effectiveness. The protocol was applied prospectively to 848 injured extremity patients to assess its safety and effectiveness. Strict adherence could reduce x‑ray use by 12 % (upper) and 19 % (lower) and save $79–139 million nationwide, but actual reductions were 5 % and 16 % due to patient demand, with only one fracture missed and satisfactory outcomes, underscoring the need for balanced cost containment. N Engl J Med.

Abstract

Abstract To help curb excessive radiography, we developed a protocol for selecting patients with injured extremities who need x-ray examination, and we tested the protocol prospectively in 848 patients to determine its safety and effectiveness. Strict adherence to the protocol would have reduced x-ray usage by 12 per cent for upper extremities and 19 per cent for lower extremities. The actual reductions were 5 per cent and 16 per cent, respectively, since further reductions were limited by patient's demands for x-ray examinations. One fracture in 287 was missed, but the treatment was appropriate and the outcome satisfactory. By eliminating superfluous x-ray procedures, the protocol could reduce charges by $79 million to $139 million nationwide, without compromising quality of care or increasing malpractice liability. Nevertheless, even the best protocol cannot eliminate all negative x-ray studies. These results should serve as a stimulus for judicious use of radiography, but also as a warning to avoid overzealous cost-containment strategies that would reduce x-ray usage to below a safe threshold. (N Engl J Med. 1982; 306:333–9.)