Recommendations

The Royal Australian College of General Practitioners

7.
Don’t order chest x-rays in patients with uncomplicated acute bronchitis.

Acute bronchitis is the commonest cause of cough presenting to GPs. It is usually viral (>90%) and self-limiting, and antibiotics should not routinely be used.

Chest x-rays (CXRs) are the imaging tests most frequently ordered by Australian GPs, and the most common indication is acute bronchitis/bronchiolitis (140,000 annually, data combined for both conditions).

‘Uncomplicated’ bronchitis refers to cough and sputum lasting less than three weeks in immunocompetent patients without underlying respiratory disease, and no clinical features suggesting pneumonia (heart rate >100, resp rate >24, temp >38.0C, haemoptysis, signs of consolidation). A Cochrane review found routine CXR did not affect outcomes in adults or children presenting to hospital with acute chest infection. Note that purulent (green) sputum is not predictive of bacterial infection and is not in itself an indication for CXR. CXRs may also lead to false positives, further investigation and unnecessary radiation. The threshold for CXR should be lower in patients over 60.

Recommendation released March 2016

Supporting evidence
  • Gordon J, Miller G, Pan Y. Ordering chest X-rays in Australian general practice. Aust Fam Physician 2015;44:537-9.
  • Michigan Quality Improvement Consortium. Management of uncomplicated acute bronchitis in adults. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Sep. 1.
  • Metlay J, Kapoor W, Fine M. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17):1440-45.
  • Cao A, Choy J, Mohanakrishnan L, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.:CD009119.
  • Albert A. Diagnosis and treatment of acute bronchitis. Am Fam Physician. 2010;1:82(11).
How this list was made How this list was made

Recommendations 1 - 5 (April 2015)

All RACGP members were invited, and five GPs selected, to join the Choosing Wisely panel. They raised 28 issues, researched these and voted on a shortlist of 10. The voting for this shortlist was based on the amount of supporting evidence available, the degree of importance for patients, and the frequency of the test or treatment being used by Australian GPs. Opinion from the entire College membership was then sought via online survey, to choose five of the shortlisted 10. Additional free-text comment was encouraged, with good response rates. This national vote determined the final five topics.

Following an NPS Representatives meeting, two on that list were found to duplicate other Colleges' choices, and it was felt the RACGP could endorse these rather than replicate them. Therefore the next two highest voted options were selected instead.

Recommendations 6-10 (March 2016)

The RACGP Working Group established for Wave 1 of Choosing Wisely identified 32 candidate topics for Wave 2, then shortlisted fifteen, spread across four categories – screening, imaging, pathology and treatment. The shortlisting criteria were: quality of supporting evidence; importance for patients; and number of Australian GPs using the test or treatment. A dedicated workshop was held at the RACGP Annual Scientific Meeting, ‘GP15’, and the entire RACGP membership was asked to vote for their ‘top five’ via online survey. Additional free-text comment was encouraged, with good response rates. The top five topics from this national vote were written up by the Working Group and reviewed by the RACGP Expert Committee – Quality Care.