Competency Assessment of Primary Health-care Physicians in Iraq Regarding the Interpretation of Chest X-ray in Acute and Emergency Conditions
Authors: Badraddin Oday Qussay , Al-Timeme Qays Ahmed 
Published: January 2025

Abstract

Background:
Primary health-care (PHC) physicians may encounter a wide variety of conditions including acute and emergent cases considering the limited access to diagnostic investigation in PHC practice. Chest X-ray (CXR) remains the imaging modality of choice to diagnose pulmonary, cardiac and other chest diseases, and it is the unique imaging technique available in Iraqi PHC centers (PHCCs), relatively inexpensive and has a low dose of radiation exposure.

Aim of the Study:
Competency assessment of diagnostic accuracy and confidence degree for Iraqi PHC physicians (PHCPs), regarding the interpretation of CXR in acute and emergent conditions.

Subjects and Methods:
A cross-sectional study that included a convenient sample of 330 participants through an online questionnaire, during the period from January 2023 to January 2024. The study included some background information such as gender, years in practice, training type, interest in pulmonary medicine and diagnostic radiology, and having adequate training on the interpretation of CXR. The questionnaire consists of 10 chest radiographs with brief clinical information for each case. Participants were asked to choose the most likely diagnosis and to rate their degree of confidence in the interpretation of the CXR for each case. Descriptive statistics were presented using tables and graphs, continuous variables summarized by mean and standard deviation. The categorical variables summarized by percentages and frequency distributions and compared using Fisher’s exact test. The level of statistical significance was set at a P < 0.05. Cutoff point of diagnostic accuracy is considered equal or more than 5 correct answers from 10 is competent, and that of confidence rate equal or more than 3 scores from 5 is confident.

Results:
Overall diagnostic accuracy is 296 (89.7%) and overall diagnostic confidence is 116 (77%). Diagnostic accuracy among family medicine specialist 164 (91.1%) and diagnostic confidence are 138 (76.7%) within their group, while among nonspecialist PHCPs, diagnostic accuracy only 132 (88%) and diagnostic confidence 116 (77.3%) within their group. Proportion of competent family medicine specialists among all competent participants was more than half 164 (55.4%) and for nonspecialists was 132 (44.6%). A moderately positive correlation (r = 0.417) between diagnostic accuracy and confidence level appeared. Cardiogenic pulmonary edema 300 (90.9%) and normal CXR 284 (86.1%) cases had the highest diagnostic accuracy scores, whereas the lowest scores were for lobar collapse 168 (50.9%) and pneumomediastinum 140 (42.4%). More than half of the participants 202 (61.2%) lived in the capital and more than three quarters of the participants 266 (80.6%) were females. Family medicine specialists was constitute the largest number 180 (54.5%) of the participants and more than half of the sample 170 (51.5%) having more than 10 years of experience. Approximately 230 (70%) of the participants had no elective rotation in diagnostic radiology and about half of the sample 162 (49.1%) were uncertain about their training adequacy. More than three quarters of the sample 258 (78.2%) interested in diagnostic radiology and 198 (60%) interested in pulmonary medicine.

Conclusions:
The competency of Iraqi PHCPs in CXR interpretation in acute and emergency conditions was optimal generally. Nonspecialist PHCPs had fewer competencies than specialists that belong to knowledge and training deficiency. An introduction of radiology training courses in emergent conditions and the use of tele-radiology platform in PHCCs should be considered.