Impact of Clinical History on Chest Radiograph Interpretation

Matthew Test, BS; Samir S. Shah, MD, MSCE; Michael Monuteaux, ScD; Lilliam Ambroggio, PhD; Edward Y. Lee, MD, MPH; Richard I. Markowitz, MD; Sarah Bixby, MD; Stephanie Diperna, MD; Sabah Servaes, MD; Jeffrey C. Hellinger, MD; Mark I. Neuman, MD, MPH


Journal of Hospital Medicine. 2013;8(7):359-364. 

In This Article

Abstract and Introduction


Background The inclusion of clinical information may have unrecognized influence in the interpretation of diagnostic testing.
Objective The objective of the study was to determine the impact of clinical history on chest radiograph interpretation in the diagnosis of pneumonia.
Design Prospective case-based study.
Methods Radiologists interpreted 110 radiographs of children evaluated for suspicion of pneumonia. Clinical information was withheld during the first interpretation. After 6 months the radiographs were reviewed with clinical information. Radiologists reported on pneumonia indicators described by the World Health Organization (ie, any infiltrate, alveolar infiltrate, interstitial infiltrate, air bronchograms, hilar adenopathy, pleural effusion).
Setting Children's Hospital of Philadelphia and Boston Children's Hospital.
Participants Six board-certified radiologists.
Outcome Measures Inter- and inter-rater reliability were assessed using the kappa statistic.
Results The addition of clinical history did not have a substantial impact on the inter-rater reliability in the identification of any infiltrate, alveolar infiltrate, interstitial infiltrate, pleural effusion, or hilar adenopathy. Inter-rater reliability in the identification of air bronchograms improved from fair (k = 0.32) to moderate (k = 0.53). Intra-rater reliability for the identification of alveolar infiltrate remained substantial to almost perfect for all 6 raters with and without clinical information. One rater had a decrease in inter-rater reliability from almost perfect (k = 1.0) to fair (k = 0.21) in the identification of interstitial infiltrate with the addition of clinical history.
Conclusions Alveolar infiltrate and pleural effusion are findings with high intra- and inter-rater reliability in the diagnosis of bacterial pneumonia. The addition of clinical information did not have a substantial impact on the reliability of these findings.


The inclusion of clinical information in diagnostic testing may influence the interpretation of the clinical findings. Historical and clinical findings may focus the reader's attention to the relevant details, thereby improving the accuracy of the interpretation. However, such information may cause the reader to have preconceived notions about the results, biasing the overall interpretation.

The impact of clinical information on the interpretation of radiographic studies remains an issue of debate. Previous studies have found that clinical information improves the accuracy of radiographic interpretation for a broad range of diagnoses,[1–4] whereas others do not show improvement.[5–7] Additionally, clinical information may serve as a distraction that leads to more false-positive interpretations.[8] For this reason, many radiologists prefer to review radiographs without knowledge of the clinical scenario prompting the study to avoid focusing on the expected findings and potentially missing other important abnormalities.[9]

The chest radiograph (CXR) is the most commonly used diagnostic imaging modality. Nevertheless, poor agreement exists among radiologists in the interpretation of chest radiographs for the diagnosis of pneumonia in both adults and children.[10–15] Recent studies have found a high degree of agreement among pediatric radiologists with implementation of the World Health Organization (WHO) criteria for standardized CXR interpretation for diagnosis of bacterial pneumonia in children.[16–18] In these studies, participants were blinded to the clinical presentation. Data investigating the impact of clinical history on CXR interpretation in the pediatric population are limited.[19]

We conducted this prospective case-based study to evaluate the impact of clinical information on the reliability of radiographic diagnosis of pneumonia among children presenting to a pediatric emergency department (ED) with clinical suspicion of pneumonia.