211 Low-dose-CT versus X-ray in patients suspected of pulmonary disease Introduction While chest X-ray (CXR) is a standard diagnostic procedure in patients suspected of non-traumatic pulmonary disease at the emergency department (ED), chest computed tomography (CT) highlights chest pathology better than CXR [1, 2]. Studies in patients with possible community-acquired pneumonia (CAP) and other non-traumatic pulmonary diseases have demonstrated that the diagnostic accuracy of CXR is limited [3-6]. Three studies showed CT markedly improved diagnostic accuracy, and subsequently changed diagnoses and clinical management [4, 5, 7]. CT also requires more radiation and increases the risk of radiation-induced cancer [8, 9]. Ultra-lowdose chest-CT (ULDCT; dose <1 mSv) has overcome this disadvantage, while preserving diagnostic accuracy for many acute pulmonary diseases that present at the ED, like pneumonia and congestive heart failure [10, 11]. The use of ULDCT reduced false-positive and false-negative CXR findings with consequences for clinical management by 20% in a prospective study in an outpatient setting [7]. Yet ULDCT is still more expensive and less accessible than CXR, and incidental findings are more prevalent [12, 13]. While the superior diagnostic accuracy could lead to faster detection of underlying conditions and timely initiation of effective treatment, incidental findings detected on ULDCT could also complicate healthcare processes, potentially prolonging hospital stay [5]. The value of a diagnostic test is not expressed by its accuracy but depends on how it affects patients health [14]. New tests should only be introduced into clinical practice when they have demonstrated to impact clinical decision making, resulting in better patient health outcomes or a simplification of the health care process [15]. Diagnostic imaging technologies that affect large numbers of patients and hold the potential to substantially increase health care costs require more extensive and more robust data on outcomes than those without these attributes [16]. At present, there is no direct evidence that patient management in the ED guided by chest-(ULD)CT rather than CXR results in better patient outcomes or a more efficient process of care; e.g. with fewer or shorter hospital admissions. We designed a multicentre non-inferiority randomised clinical trial in which we randomly allocated consenting ED patients suspected of non-traumatic pulmonary disease to either ULDCT or CXR. The link between imaging and health outcomes is an indirect one, and superior accuracy is not guaranteed to lead to improved health outcomes [16]. We did not expect ULDCT to lead to better patient outcomes but anticipated that it would result in functional health after 28 days at least as good as obtained with CXR, hence the noninferiority design. In addition, we hypothesized that improved detection of underlying conditions with ULDCT would lead to a more efficient health care process, reflected in fewer hospital admissions and a shorter hospital length of stay, compared with CXR. 9
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