210 Chapter 9 Key messages What is already known on this topic • Several studies underscore the higher diagnostic accuracy of chest CT as compared to CXR, but since no patient outcome measures were collected, the effectiveness of both strategies cannot be compared. What this study adds • Our randomised trial is unique in its aim to assess the yield of replacing CXR by ULDCT in the diagnostic work-up of emergency department patients suspected of non-traumatic pulmonary disease in terms of patient outcomes and health care efficiency. We showed that ULDCT leads to functional health outcomes at 28 days that are at least similar to those obtained if management is guided by CXR, while resulting in minimal differences in hospital admission rates, length of stay, and mortality rates. How this study might affect research, practice or policy • The results of our study enforces the current guidelines that adhere to CXR as first line imaging technique. Future research should focus on subgroups of patients that might benefit of ULDCT. Abstract Background: Chest CT displays chest pathology better than chest X-ray (CXR). We evaluated the effects on health outcomes of replacing CXR by ULDCT in the diagnostic work-up of patients suspected of non-traumatic pulmonary disease at the emergency department. Methods: Pragmatic, multicentre, non-inferiority randomised clinical trial in patients suspected of non-traumatic pulmonary disease at the emergency department. Between January 31, 2017 and May 31, 2018, every month, participating centres were randomly allocated to using ULDCT or CXR. Primary outcome was functional health at 28 days, measured by the Short Form (SF)-12 physical component summary scale score (PCS score), non-inferiority margin was set at 1 point. Secondary outcomes included hospital admission, hospital length of stay (LOS), and patients in follow-up because of incidental findings. Results: 2418 consecutive patients (ULDCT: 1208, CXR: 1210) were included. Mean SF-12 PCS score at 28 days was 37.0 for ULDCT and 35.9 for CXR (difference 1.1; 95% lower confidence interval: 0.003). After ULDCT, 638/1208 (52.7%) patients were admitted (median LOS of 4.8 days; IQR 2.1 to 8.8) compared to 659/1210 (54.5%) patients after CXR (median LOS 4.6 days; IQR 2.1 to 8.8). More ULDCT patients were in follow-up because of incidental findings: 26 (2.2%) versus 4 (0.3%). Conclusions: Short-term functional health was comparable between ULDCT and CXR, as were hospital admissions and LOS, but more incidental findings were found in the ULDCT group. Our trial does not support routine use of ULDCT in the work-up of patients suspected of non-traumatic pulmonary disease at the emergency department.
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