Immediate reporting of chest X-rays referred from general practice by reporting radiographers: a single centre feasibility study.

AIM: To investigate the feasibility of radiographer-led immediate reporting of chest radiographs (CXRs) referred from general practice.
MATERIALS AND METHODS: This 4-month feasibility study (November 2016 to March 2017) was carried out in a single radiology department at an acute general hospital. Comparison was made between CXRs that received an immediate and routine report to determine the number of lung cancers diagnosed, time to diagnosis of lung cancer, time to computed tomography (CT), and number of urgent referrals to respiratory medicine.
RESULTS: Forty of 186 sessions (22%) were covered by radiographer immediate reporting. Of the 1,687 CXRs referred from general practice, 558 (33.1%) received an immediate report (radiographer or radiologist). Twenty-two (of 36) CT examinations performed were following an abnormal CXR with an immediate report (mean 0.8 scans/week). Time from CXR to CT was shorter in the immediate report group (n=22 mean 0.9 days SD=2.3) compared to routine reporting (n=14; mean 6.5 SD=3.2; F=27.883, p<0.0001). Time to multidisciplinary team (MDT) discussion was shorter in the immediate reporting group (mean 4.1 SD=2.9) compared to routine reporting (mean 10.6; SD=4.5; F=11.59, p<0.0001). No apparent difference was found for time to discussion at treatment MDT.
CONCLUSION: It is feasible to introduce a radiographer-led immediate CXR reporting service. Patients can be taken off the lung cancer pathway sooner with the introduction of radiographer immediate reporting of CXRs and this may improve outcomes for patients. A definitive study assessing outcomes is required to determine whether this will have an impact mortality and morbidity for patients.

Introduction

Cancer is one of the most common causes of mortality, and lung cancer is the largest cause of cancer deaths. When compared to other high-resource nations such as the USA, Europe, and Australia, England demonstrates lower survival for all cancer types and, in particular, lung cancer. Worse outcomes for lung cancer, when compared to other common cancers, such as breast and bowel, is often due to late stage at diagnosis, which reduces treatment options.3, 4 The reason for late diagnosis is multifactorial: vague and non-specific symptoms, no current established screening programme, and higher prevalence in lower socioeconomic groups that often do not engage with health services.5, 6, 7

In order to address the late stage at diagnosis and improve outcomes, several initiatives are being implemented. Promising results were reported from the UK Lung Screening (UKLS) pilot study that examined lung cancer screening with low-dose computed tomography (CT) in high-risk patients. Work is also being conducted to identify risk factors and high-risk patients in general practice,5, 9 and recent guidance has lowered the threshold for investigation of suspected cases of lung cancer.10, 11

The Lung Cancer Clinical Expert Group published an optimal pathway for the diagnosis and treatment of lung cancer in 2016. In order to improve outcomes, the pathway emphasised the need for early and accurate diagnosis, and proposed immediate reporting of chest radiographs (CXR) referred from general practice, with immediate CT of the chest for cases suspicious for malignancy. Streamlined diagnostics, with all radiology investigations performed and reported within 24 hours, was identified as a method of fast-tracking patients into the lung cancer pathway or giving patients a rapid non-cancer diagnosis.

A significant barrier to successful implementation of the optimal pathway is the ability of radiology departments to provide immediate CXR reporting and CT chest examinations. Diagnostic capacity is frequently cited as a barrier to improved cancer outcomes,13, 14 with significant reporting backlogs in England.15, 16 These delays have been exacerbated by sustained increases in imaging demand, and a scarcity of consultant radiologists. Radiographers that have completed accredited postgraduate education have been providing clinical reports for a range of imaging examinations as one method to increase capacity. This includes the reporting of skeletal radiographs,17, 18 magnetic resonance imaging (MRI) of knee and lumbar spine examinations19, 20 and, increasingly, CXRs,21, 22 and there is a growing evidence base to support this practice. The aim of this project was to perform a single-centre feasibility study on an immediate CXR reporting service, by radiographers, for patients referred from general practice.

Materials and methods

This project was an evaluation of a new service, and as such ethical approval was not required. The primary outcome was to establish the feasibility of immediate reporting, in terms of resource requirement assessment and practical limitations. The number of CXR reports provided by each practitioner was retrieved from the Radiology Information System (RIS; 2016–2017). Secondary outcomes were the number of lung cancers diagnosed, the time to diagnosis of lung cancer (including intermediate time points; time to CT, time to diagnostic multidisciplinary team [MDT]), and the number of urgent referrals to respiratory medicine. All timing (time to CT, time to diagnostic MDT) was measured in days, including weekends, not working days. Comparisons were made for urgent respiratory referrals that received an immediate CXR report and those that received a routine report. Patients with a non-cancer CXR report and that had a CT performed by respiratory medicine were stratified by timing of the CXR report (immediate or routine) to explore if there was a difference in the proportion of patients referred for additional investigations in secondary care. Descriptive statistics, including mean, standard deviation (SD), and median and interquartile range (IQR), were calculated. One-way t-test, analysis of variance (ANOVA) and Fisher's exact test were used to identify trends (SPSS version 22).

Department demographics

The feasibility study was conducted at Homerton University Hospital, an acute district general hospital in London, UK. This imaging department performs approximately 173,000 examinations per year, 88,900 radiography examinations, of which 5,100 are adult CXRs referred from general practice (2016–2017). Homerton University Hospital has an established team of advanced (n=6) and consultant (n=1) radiographers. At the time of the feasibility study, only one reporting radiographer was providing CXR reports in clinical practice. A further two radiographers had recently completed accredited postgraduate education and were undertaking a period of double reporting. The department provides a walk-in GP radiography service between 8:00–17.00 Monday to Friday. For the purposes of the present study, a session was defined as a half day (4.5 hours) between 8:00–12:30 or 12:30–17:00.

Reporting radiographer

CXRs from general practice were reported by a single radiographer, who completed a postgraduate certificate in adult CXR reporting in 2010 and is an accredited consultant radiographer with the College of Radiographers. The radiographer reports 8,000 adult CXRs per year, is an active member of the respiratory MDT and has been discussing abnormal CXRs with patients on an ad-hoc basis for 3 years after completion of advanced communication skills training.

Implementation of immediate CXRs referred from general practice

The study was conducted between November 2016 and March 2017. All adult (>16 years) CXRs referred from general practice during an immediate reporting session received a report prior to the patient leaving the department. CXRs that were suspicious for lung cancer were discussed with a consultant radiologist, who requested the CT examination. The reporting radiographer informed the patient, explained the findings, and an immediate CT examination of the chest was offered. Results of the CT examination were fast-tracked and made available to the general practitioner and lung cancer co-ordinator the following session. Patients were advised to request an urgent appointment. CXRs that demonstrated other significant disease were referred for appropriate management according to the departmental protocol for urgent and unexpected findings.

Routine CXR reporting

CXRs not performed during an immediate radiographer CXR reporting session were reported routinely under the usual protocol, which is that a consultant radiologist reports the CXR within 1 working day, after the patient has left the department. Any further tests require recall of the patient. Current practice for CXRs that receive a routine report does allow for escalation for an urgent, immediate radiologist report. If the radiographer or assistant practitioner performs a CXR that is suspicious for cancer, this will be triaged for an immediate consultant radiologist or reporting radiographer report. If the report raises suspicion of lung cancer an immediate CT examination of the chest is offered to the patient. Fast track for an immediate report requires the radiographer performing the CXR to recognise the case as suspicious for cancer, and is often triggered for more obvious abnormalities.

Results

CXR referrals from general practice

A total of 1,687 CXRs referred from general practice were performed. Of these, 558 (33.1%) CXRs received an immediate report. The majority (n=552; 98.9%) of immediate reports were provided by a reporting radiographer. Six patients (1%) were fast-tracked by the performing radiographer for an immediate consultant radiologist report. The remaining 1,129 (66.9%) received a routine consultant radiologist report. CXRs that did not receive an immediate report were all reported no later than next working day, in line with local maximum reporting times. Mean age of all patients referred for a CXR was 52.7 years (SD=16.7), with no significant difference between patients that received an immediate (mean 53.9; SD=16.8) or routine (mean 52.4; SD=16.6) CXR report (F=1.978; p=0.16).

Immediate CXR reporting sessions

During the evaluation period a total of 40 out of 186 sessions (22%) had a radiographer undertaking immediate reporting. The radiographer reported a mean of 13.5 CXRs from general practice per session (range 1–28 per session). Seven additional reporting sessions during the 4-month evaluation period that did not include immediate reporting were provided by the radiographer.

A total of 4,522 radiography examinations were reported by the radiographer during 47 reporting sessions (mean 96.2 reports per session), of which 3,459 were adult CXRs. In comparison, the radiographer reported a total of 5,256 X-rays (3,315 CXRs) over the corresponding period the previous year (2015–2016) in 57 reporting sessions, with a mean number of 92.2 reports per session. The additional CXR reports reported by the radiographer during the study period were from other referral sources (emergency department, inpatients, outpatients). Eleven consultant radiologists provided adult CXR reports during the study period. The mean volume per radiologist was 568.2 (SD=328.9) with a range of 63 to 1,011.

Logistics and implementation of immediate CXR reporting

Immediate reporting of CXRs referred by general practice required a change in the system of work within the radiology department. In order to minimise disruption to patients, radiographers, the CT department, and radiologists a staged approach was used. The study centre has a radiographer-led immediate reporting of skeletal examinations referred from the emergency department and for trauma skeletal examinations referred from general practice. The system of work was adapted from this model. For the first month of the study (November 2016), a target of one session per week (4 of 22; 18%) received an immediate radiographer CXR report. This enabled a system of work to be piloted and amended.

Feedback from the radiographers and radiologists was integrated into the definitive workflow. The reporting radiographer was assigned a “hot desk” with dedicated telephone extension and agreed to be available for the duration of the session. In order to minimise impact on patient throughput in the radiography imaging area a “sub-waiting” area was created for patients that had their examination performed and were waiting for their report.

Prior to CT, patients that have a suspicious CXR require a practitioner to explain the result, the significance of the findings, outline the next steps in the pathway, and answer any questions. During the pilot study, this role was undertaken by the radiographer. Discussion with the patient was completed within 10 minutes with minimal impact on workflow.

CT impact

A total of 36 patients (22 immediate CXR report, 14 routine CXR report) had a CT scan arranged by radiology following a suspicious CXR. Over the course of the feasibility study, less than one additional unplanned patient per week (26 week study period, mean 0.8 scans per week) were accommodated by the CT department. Patients that required CT had their electronic patient record checked for renal function. Recent research suggests little contribution of the use of contrast media in causing acute kidney injury (AKI). Patients with below normal baseline renal function (estimated glomerular filtration rate [eGFR] <90) or no recent renal function were risk stratified for risk of AKI following intravenous contrast medium according to local protocol. If renal function was poor (eGFR <45) an unenhanced CT examination of the chest was performed. Only one instance (of 22; 5%) required renal function testing prior to CT and the patient was offered an appointment for a CT examination the following day.

Urgent referrals to respiratory medicine for suspected cancer

A total of 128 urgent referrals for cases of suspected lung cancer were received by respiratory medicine. One hundred and five (82%) were referred by a general practitioner. Eleven (9%) emergency medicine, three (2%) outpatient, one (1%) inpatient referral, and eight (6%) referrals from external hospitals were also received. Urgent referrals that did not have a CXR referred from general practice performed at the study site were excluded from analysis. No apparent difference was found between time from referral to first urgent respiratory appointment for immediate or routine CXR reports (Fig 1; F=0.134; p=0.875).

Figure 1

Mean time in days between CXR and CT chest examinations, first respiratory appointment, and diagnostic MDT discussion. RR, reporting radiographer; CR, consultant radiologist; DMDT, diagnostic MDT.

Time from CXR suspicious for cancer to CT

A total of 36 patients underwent CT after a CXR that was suspicious for lung cancer (Table 1). A total of 22 patients (of 558; 3.9%) that received an immediate report, either radiologist (n=6) or radiographer (n=16), had CXR findings that were suspicious for lung cancer. Of the CXRs that received a routine report, 14 (1%) had findings that were suspicious for lung cancer. The mean and median time from CXR to CT, respiratory appointment, and diagnostic MDT discussion are presented in Figure 1, Figure 2, respectively. The time to CT scan (F=27.883; p<0.0001) and discussion at diagnostic MDT (F=19.508; p<0.0001) was shorter in those patients who received an immediate report (radiographer or radiologist) than in those that received a routine report.

Table 1

Summary of radiological diagnoses for patients that underwent computed tomography examination of the chest.

Pathology group	Radiological diagnosis	Number of cases
		Immediate radiographer report	Immediate radiologist report	Routine radiologist report
Normal		3	0	2
Lung nodule	Lung cancer	5	6	8 (3 on follow-up)
	Benign lung nodule	2	0	0
Infective	Pneumonia	3	0	1
	Tuberculosis	1	0	0
Interstitial	Interstitial lung disease	0	0	2
	Bronchiectasis	0	0	1
Pleural	Pleural plaque	1	0	0
	Pleural fibroma	1	0	0
Total		16	6	14

Figure 2

Median time in days between CXR and CT chest examinations, first respiratory appointment, and diagnostic MDT discussion. RR, reporting radiographer; CR, consultant radiologist; DMDT, diagnostic MDT.

Lung cancer diagnoses

Eleven patients that received an immediate report had a radiological diagnosis of lung cancer with eight (72.7%) confirmed at histology. The mean and median times to discussion at diagnostic and treatment MDTs are presented in Table 2. Of the three cases that were negative for malignancy at histology, one case had confirmed tuberculosis (TB), the other two are undergoing radiological follow-up for presumed infection. The time to diagnostic MDT discussion was shorter in those patients who received an immediate report than those that received a routine report (F=11.59; p<0.0001). No apparent difference was found between patients who received an immediate or routine CXR report in the time between referral to respiratory medicine and discussion at the treatment MDT (F=0.240; p=0.792).

Table 2

Mean and median time to diagnostic MDT and treatment MDT discussion for cases with a radiological diagnosis of presumed lung cancer and an immediate CXR report.

Histological diagnosis	No.	Time to diagnostic MDT		Time to treatment MDT
		Mean (SD)	Median (IQR)	Mean (SD)	Median (IQR)
Lung cancer	8	0.85 (2.3)	0 (0)	20.75 (11.6)	20.5 (14.5–25)
Non-cancer	3	3.7 (2.9)	2 (2)	20 (6.6)	21 (13–21)

RR = reporting radiographer; CR = consultant radiologist; DMDT = diagnostic multidisciplinary team; TMDT = treatment multidisciplinary team.

CT performed with a non-cancer CXR report

Seventy-eight patents with a non-cancer diagnosis on CXR (11 immediate report, 67 routine report) were referred for an urgent respiratory appointment from general practice. Of the 11 patients with a non-cancer immediate report, seven (63.6%) had a CT performed in comparison to 47 (of 67, 70%) who had a non-cancer routine CXR report. No apparent difference was found between the proportion of immediate and routine CXR reports that had a subsequent CT (Fisher's exact test p=0.729).

Seventeen patients that had a normal or non-cancer diagnosis at CXR referred by general practice were subsequently diagnosed with lung cancer. Two cases, one immediate (radiographer) and one routine (consultant radiologist) were incorrectly diagnosed as non-cancer diseases (Table 3). The remaining 15 cases had lung cancer that was not identifiable on CXR; two immediate (of 558; <1%) and 13 routine (of 1,128; 1%).

Table 3

Incorrect non-cancer chest radiograph (CXR) diagnoses and time in days to computed tomography (CT), diagnostic multidisciplinary team (MDT) and treatment MDT discussion.

	CXR diagnosis	Time to CT	Time to diagnostic MDT	Time to treatment MDT
Immediate RR report	COPD	49	56	63
Routine CR report	Sarcoidosis	31	33	46

RR, reporting radiographer; CR, consultant radiologist; COPD, chronic obstructive pulmonary disease.

Non-cancer diagnoses with suspicious CXR

Seventeen patients received a suspicious CXR report (n=11 immediate; n=6 routine) and underwent CT with a non-cancer radiological diagnosis (Table 1). The most common non-cancer diagnosis for radiologist and radiographer reports was infection and included two cases of TB (7, 41%). Patients with an immediate abnormal CXR and an immediate non-cancer diagnosis CT report were not referred to respiratory medicine on seven (of 11, 64%) occasions and were managed in primary care. Time to diagnostic MDT, and thus discharge from the lung cancer pathway, was shorter for an immediate CXR report (mean 2.5 days, SD=2.5) than a routine report (mean 11 days, SD=4.3). Two pneumothoraces were diagnosed in the immediate reporting sessions, and the patients referred to the emergency department. One patient with an abnormal CXR suspicious for cancer had extensive, bilateral pulmonary emboli and was referred to the acute medical team for management.

Follow-up CXRs

In line with British Thoracic Society guidance, all CXRs reported as showing pneumonia had a follow-up CXR suggested in 4–6 weeks to ensure resolution. Of the 17 cases (of 522, 3%) where a follow-up CXR was suggested, four (22%) were performed with mean time from initial to follow-up CXR of 33.8 days (range 10–49 days). One repeated CXR demonstrated persistent left basal changes, and a subsequent CT diagnosed bronchiectasis. In the remaining 13 cases, the follow-up CXR was not performed in the authors' hospital and it was assumed follow-up CXRs were not performed. During the study period, there was no recall or reminder mechanism in place.

Discussion

Results from this feasibility study suggest that implementing an immediate, radiographer-led CXR reporting service for general practitioner referrals is achievable. During the trial period, 33.1% of CXRs received an immediate report (552, 32.7% radiographer) and 22 of the 558 CXRs reported resulted in early CT. Those patients who had a CXR immediately and subsequently underwent CT were scanned more promptly and their cases were discussed more promptly at a diagnostic MDT meeting. Capacity for immediate CT of patients with a suspicious CXR was not a barrier to implementation.

Strengths and limitations

To the authors knowledge, this the first study that has investigated the feasibility of immediate CXR reporting by a reporting radiographer. The immediate CXR reporting service for general practice referrals in this study was provided by a single, experienced reporting radiographer. The provision of this service during the trial phase was dependent on availability. The results of this study, while promising, cannot yet be generalised to other reporting radiographers, for instance, the mean number of reports provided per session. The small number of CXRs included (n=1,687; n=558 immediate report) and few diagnoses of lung cancer (n=19; n=11 immediate report) limit the assessment on time to diagnosis of lung cancer and the relative false-positive and false-negative results.

Recent guidance on optimising the lung cancer pathway suggests that each practitioner provides a minimum of 2,000 adult CXR reports per annum. Concentrating reporting within a team of experienced, high-volume practitioners is hoped to improve accuracy, similar to reporting requirements for screening mammography. The single reporting radiographer in the current study reports 8,000 adult CXRs per year.

The National Optimal Lung Cancer Pathway advocates immediate reporting of all CXRs referred by general practice. During the feasibility study, this was only achieved for 22% (40 of 186 sessions) due to staffing requirements. The main barrier to the successful implementation of immediate reporting is reporting resource, with appropriately trained staff required to be “on-call” to provide a report as and when the patient attends radiology. The study site introduced immediate reporting of trauma skeletal radiographs in January 2016 in line with National Institute for Health and Care Excellence (NICE) guidance with a team of six skeletal reporting radiographers. The team of CXR reporting radiographers has since been expanded, with an additional two reporting radiographers successfully completing their audit period (double reporting of all CXRs) in December 2017, two trainee CXR reporting radiographers due to sit their final examinations in November 2017 and two new trainees commencing postgraduate education in September 2017. Sustainable implementation requires multiple practitioners to provide robust, reliable service that can account for leave, sickness, and other responsibilities. A critical mass of seven CXR reporting radiographers will be achieved at the study centre by September 2018.

The results of this single-centre feasibility study do suggest that it is feasible to introduce such a service, and this may decrease the time to diagnosis of lung cancer, discharge from the lung cancer pathway, and reduce the number of urgent referrals to respiratory medicine. Seven patients with an immediate CXR report and CT were managed in primary care, with all 14 patents with a routine CXR report and CT referred to respiratory medicine.

Reporting of adult CXRs by trained radiographers has shown to be accurate, safe, and effective in several diagnostic accuracy studies.21, 22, 28 The single reporting radiographer in the current study interpreted 16 cases as suspicious for lung cancer, with diagnosis confirmed at subsequent CT in five cases (31%). When compared to the historical29, 30 and contemporary literature,31, 32 significant variation in CXR reporting exists with an estimated 20% of patients subsequently diagnosed with lung cancer having a normal CXR. CXRs interpreted as normal by the reporting radiographer were not reviewed by another practitioner, and as such false negatives may have occurred. Two cases in the current study received a false-negative CXR report, one radiographer (anterior mediastinal mass only visible on CT) and one radiologist (presumed sarcoidosis).

Patients with a CXR suspicious for cancer that received an immediate report (n=22) had a similar proportion of false positives (non-cancer diagnosis 9 of 22; 41%) when compared to CXRs that had a suspicious CXR reported routinely (non-cancer diagnosis 6 of 14; 42%). When stratified by reporting practitioner, the immediate radiographer CXR reports had a higher false-positive rate (9 of 16; 56%) than the immediate consultant CXR report (0 of 6; 0%) and routine radiologist report (6 of 14; 42%). All cases triaged by the radiographer performing the CXR for an immediate CXR report had obvious abnormalities and this explains the absence of false-positive diagnosis in this group. An apparent difference in false-positive rate between radiographer (56%) and radiologist (42%) report may be due to the radiographer adopting a more conservative approach than the radiologist; however, during the current study, all CXRs suspicious for cancer were reviewed by a consultant radiologist who agreed that the CXR was suspicious for cancer and requested the CT. It may be that incorporation bias was present, as the radiographer discussed the case directly with the radiologist. Further research, which includes a larger number of CXRs that receive an independent double report, would provide more robust results.

A higher proportion of patients referred via the urgent lung cancer pathway that had a routine CXR report (47 of 1,129, 1%) had a CT performed by respiratory medicine that an immediate report (7 of 528, <1%). It may be that a proportion of the additional CT examinations performed due to a radiographer immediate report (radiographer false positive rate, non-cancer diagnosis on CT) may have had a CT requested by respiratory medicine to investigate suspected lung cancer cases. The National Optimal Lung Cancer Pathway advocates chest CT referred by primary care for high-risk patients with a normal CXR, preferably immediately. Further work could address possible triage of high-risk patients to immediate CT chest with a non-cancer CXR immediate report.

Lung cancer diagnosis and prevalence in the literature

Improvement of the patient diagnosis pathway has been the focus of previous work. A tertiary referral department in England recently piloted radiology-generated requests for CT chest examinations based on a general practitioner referred CXR that was suspicious for lung cancer. During the 6-month evaluation, 111 of 3,102 (3.7%) patients had a CT examination arranged on the basis of an abnormal CXR, with a reduction in mean time from CXR to CT from 19 to 7 days. Thirty patients (of 103 CT examinations performed, 29.1%) subsequently had a radiological diagnosis of lung cancer. In comparison with the current study, a greater number of CXRs were included (3,102 compared to 528), and more cases of lung cancer diagnosed (103 radiological diagnoses compared to 11), although the mean time from suspicious CXR in the current study of 0.85 days for immediate reporting and 6.5 days for routine reporting time compared to 7 days is favourable.

Implications for practice and research

In order to streamline the patient pathway, an immediate CT examination of the chest is suggested for all CXRs that are suspicious for lung cancer. There is also evidence to suggest that the delay between having an investigation and receiving the results is an anxious time for patients.34, 35 Streamlining this aspect of the pathway may improve the patient experience and outcomes. Firstly, this requires the CXR to be reported while the patient is in the imaging department, and the results of this study demonstrate that this is feasible. Secondly, a practitioner is required to have a discussion with the patient, explain the findings of the CXR, including possible diagnoses, and outline the next steps in the diagnostic pathway as well as providing answers to any questions the patient may have. Evidence suggests that patients are comfortable receiving the results of imaging investigations in radiology.34, 36 If immediate CXR reporting is to be provided by radiographers, they would be required to discuss results with patients. Evidence from obstetrics indicates that with appropriate training sonographers frequently communicate distressing results. The radiographer in the current study had completed advanced communication skills training in preparation for this, and had access to senior clinicians, radiologists, and chest physicians for mentorship. If other departments implement a radiographer-led immediate CXR reporting service then training and support would be required.

The impact of shorter time to diagnosis of lung cancer is debated in the literature. Some evidence suggests that even a modest reduction in time to diagnosis of lung cancer can have a positive effect on patient survival and outcome. The results of this feasibility study found a reduction in time to diagnostic MDT with immediate CXR reporting and CT, although a small number of lung cancers were diagnosed. In addition, decisions to discharge from the lung cancer pathway are frequently made at diagnostic MDT. Shorter times to diagnostic MDT could possibly reduce patient anxiety and help meet the 2020 diagnosis or discharge target. Further planned research with a larger sample size will help address this question.

General practitioners in the UK often do not have access to the radiological images, unlike hospital-based clinicians, and are therefore unable to perform a clinical review and interpretation. General practitioners are thus reliant on a prompt and accurate clinical report to maximise the benefit to the patient of the CXR and to optimise treatment decisions. This study suggests that, where appropriate resource exists, that it is feasible to implement radiographer-led immediate CXR reporting.

This project has demonstrated that it is feasible to introduce immediate reporting of CXRs referred from general practice by radiographers. The methodology developed and data collection tools developed for this feasibility study have formed the basis for a 12-month evaluation, powered to detect a clinical and statistical difference, if one exists, between immediate and routine reporting and time to diagnosis of lung cancer. Ten sessions per week will be covered by one of three CXR reporting radiographers with five sessions per week block randomised to either an immediate or routine CXR report. External funding has been secured and data collection commenced in July 2017.

In conclusion, the call for prompt radiology investigations and reporting as a method to improve outcomes for lung cancer is not recent; however, progress has unfortunately been variable. Given the well-documented delays to reporting and general diagnostic capacity issues, it is time to trial bold, novel solutions in a bid to improve patient care and outcomes. The results of this study suggest that it is feasible to implement radiographer-led immediate CXR reporting into clinical practice and such pathways may lead to more prompt investigation and discussion at an appropriate MDT meeting. Furthermore, unnecessary referrals to a respiratory medicine clinic may be avoided. Further larger scale studies are indicated.