Chest X-Ray Has Poor Diagnostic Accuracy and Prognostic Significance in COVID-19: A Propensity Matched Database Study

Borakati, A.; Perera, A.; Johnson, J.; Sood, T.

Objectives: To identify the diagnostic accuracy of common imaging modalities, chest X-ray (CXR) and computed tomography (CT) for diagnosis of COVID-19 in the general emergency population in the UK and to find the association between imaging features and outcomes in these patients. Design: Retrospective analysis of electronic patient records Setting: Tertiary academic health science centre and designated centre for high consequence infectious diseases in London, UK. Participants: 1,198 patients who attended the emergency department with paired RT-PCR swabs for SARS-CoV 2 and CXR between 16th March and 16th April 2020 Main outcome measures: Sensitivity and specificity of CXR and CT for diagnosis of COVID-19 using the British Society of Thoracic Imaging reporting templates. Reference standard was any reverse transcriptase polymerase chain reaction (RT-PCR) positive naso-oropharyngeal swab within 30 days of attendance. Odds ratios of CXR in association with vital signs, laboratory values and 30-day outcomes were calculated. Results: Sensitivity and specificity of CXR for COVID-19 diagnosis were 0.56 (95% CI 0.51-0.60) and 0.60 (95% CI 0.54-0.65), respectively. For CT scans these were 0.85 (95% CI 0.79-0.90) and 0.50 (95% CI 0.41-0.60), respectively. This gave a statistically significant mean increase in sensitivity with CT compared with CXR, of 29% (95% CI 19%-38%, p<0.0001). Specificity was not significantly different between the two modalities. Chest X-ray findings were not statistically significantly or clinical meaningfully associated with vital signs, laboratory parameters or 30-day outcomes. Conclusions: Computed tomography has substantially improved diagnostic performance over CXR in COVID-19. CT should be strongly considered in the initial assessment for suspected COVID-19. This gives potential for increased sensitivity and considerably faster turnaround time, where capacity allows and balanced against excess radiation exposure risk.