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Appropriateness Criteria

Variant 1: Child. 3 months of age and older. Immunocompetent. Suspected uncomplicated community-acquired pneumonia in a well-appearing child who does not require hospitalization. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US chest Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 9 2 3 1 1 0 0 0 0
References Study Quality
27 (29112644) Good
26 (29043420) 4
29 (26923626) 1
28 (27749801) 3
25 (25780071) Good
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 6 5 5 0 0 0 0 0 0
References Study Quality
24 (29043422) 4
4 (21903691) 4
3 (21880587) 4
23 (24369343) 4
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
Variant 2: Child. 3 months of age and older. Immunocompetent. Community-acquired pneumonia that does not respond to initial outpatient treatment or requires hospital admission. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 0 0 0 3 13
References Study Quality
24 (29043422) 4
3 (21880587) 4
30 (29658199) 3
US chest May be appropriate Moderate O 0 mSv O 0 mSv [ped] 4 4 3 1 2 5 4 0 0 1 0
References Study Quality
27 (29112644) Good
26 (29043420) 4
29 (26923626) 1
28 (27749801) 3
25 (25780071) Good
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 0 0 1 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 0 0 0 0 0 0
Variant 3: Child. 3 months of age and older. Immunocompetent. Suspected hospital-acquired pneumonia. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 9 9 0 0 0 0 2 0 1 2 11
References Study Quality
11 (26527358) 4
10 (19648731) 4
US chest May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 7 0 1 5 2 0 0 1 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 0 0 2 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
Variant 4: Child. Immunocompetent. Pneumonia complicated by suspected moderate or large parapneumonic effusion by chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US chest Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 3 2 10
References Study Quality
26 (29043420) 4
38 (28301494) 3
16 (27709281) 3
31 (23164006) 4
39 (19933660) 3
34 (19198826) 4
36 (16906429) 2
35 (9609186) 4
33 (14695718) 2
Radiography chest decubitus view May be appropriate Expert Consensus ☢ <0.03 mSv [ped] 6 6 0 0 0 2 4 7 3 0 1
CT chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 4 3 4 3 1 0
References Study Quality
31 (23164006) 4
34 (19198826) 4
36 (16906429) 2
35 (9609186) 4
37 (9207521) 3
MRI chest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 2 3 1 3 0 0 0 0
References Study Quality
41 (29043418) 4
44 (18726093) 4
43 (21816896) 3
40 (23701075) 2
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 2 1 3 2 0 0 0 0
References Study Quality
41 (29043418) 4
44 (18726093) 4
43 (21816896) 3
40 (23701075) 2
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 4 1 1 0 1 0 0 0
References Study Quality
31 (23164006) 4
34 (19198826) 4
36 (16906429) 2
35 (9609186) 4
37 (9207521) 3
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 3 3 0 0 0 0 0
References Study Quality
31 (23164006) 4
34 (19198826) 4
36 (16906429) 2
35 (9609186) 4
37 (9207521) 3
Variant 5: Child. Immunocompetent. Pneumonia complicated by suspected bronchopleural fistula by chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 2 6 8
References Study Quality
45 (20118715) 4
CT chest without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 2 4 5 1 0 2
References Study Quality
45 (20118715) 4
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 0 0 1 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 0 1 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 1 0 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 3 2 1 1 0 0 1 0
References Study Quality
45 (20118715) 4
Variant 6: Child. Immunocompetent. Pneumonia complicated by suspected lung abscess by chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 4 12
References Study Quality
13 (29043419) 4
46 (26785088) 4
47 (26086718) 2
31 (23164006) 4
35 (9609186) 4
19 (11870440) 4
US chest May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 9 1 0 0
References Study Quality
49 (19255298) 2
50 (1683367) 3
51 (2052687) 4
MRI chest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 4 3 1 1 6 1 0 0 0
References Study Quality
41 (29043418) 4
40 (23701075) 2
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 3 2 0 3 2 0 0 0
References Study Quality
41 (29043418) 4
40 (23701075) 2
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 2 1 0 0 1 0 0
References Study Quality
13 (29043419) 4
46 (26785088) 4
47 (26086718) 2
31 (23164006) 4
35 (9609186) 4
19 (11870440) 4
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 2 3 0 0 0 0 0
Variant 7: Child. 3 months of age and older. Immunocompetent. Recurrent nonlocalized pneumonia by chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 1 0 0 0 0 1 3 4 7
References Study Quality
52 (23169612) 2
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 4 3 1 1 0 0 0 0
References Study Quality
53 (21943039) 2
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 3 3 4 0 0 0 0 0
References Study Quality
53 (21943039) 2
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 4 1 4 0 1 0 0
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 4 2 0 1 0 0 0 0
References Study Quality
52 (23169612) 2
Variant 8: Child. 3 months of age and older. Immunocompetent. Recurrent localized pneumonia by chest radiograph. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 1 2 4 7 2
References Study Quality
13 (29043419) 4
21 (22726867) 4
58 (27723920) 4
62 (27659701) 3
60 (27464296) 2
61 (24234181) 3
55 (23378160) 3
52 (23169612) 2
63 (22956521) 2
59 (22087520) 4
54 (21512069) 2
56 (18718229) 2
57 (17527118) 3
CTA chest with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 1 0 1 0 0 0 1 3 10
References Study Quality
63 (22956521) 2
59 (22087520) 4
CT chest without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 0 5 4 3 2 0 0
References Study Quality
13 (29043419) 4
21 (22726867) 4
58 (27723920) 4
62 (27659701) 3
60 (27464296) 2
61 (24234181) 3
55 (23378160) 3
52 (23169612) 2
63 (22956521) 2
59 (22087520) 4
54 (21512069) 2
56 (18718229) 2
57 (17527118) 3
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 3 5 2 0 0 0 0 0
References Study Quality
53 (21943039) 2
MRI chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 4 2 0 0 0 0 0 0
References Study Quality
53 (21943039) 2
CT chest without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 4 3 0 0 0 0 0 0
References Study Quality
13 (29043419) 4
21 (22726867) 4
58 (27723920) 4
62 (27659701) 3
60 (27464296) 2
61 (24234181) 3
55 (23378160) 3
52 (23169612) 2
63 (22956521) 2
59 (22087520) 4
54 (21512069) 2
56 (18718229) 2
57 (17527118) 3
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.