6. Project Abstract: Identifying unnecessary irradiation of patients with suspected renal colic Up to 12% of the population has kidney stones, and 3-5% of all persons are likely to experience an episode of renal colic in their lifetime, many of whom will present to the Emergency Department (ED) for evaluation. Computed tomography (CT) scanning is now a first-line test for suspected renal colic, and is accurate in detecting stones. However CT scanning involves significant amounts of ionizing radiation, is costly, may lead to further unnecessary testing, and rarely alters management as most kidney stones pass spontaneously. CT scanning has increased dramatically in the U.S. over the last several decades, from approximately 3 million scans done in 1980 to over 60 million in 2007. In the year 2000 there were ~12 scans per 100 people, nearly doubling to ~22 per 100 people in 2005;during that time Medicare expenditures for imaging increased from $6.2 billion to $12 billion, accounting for 23% of all Medicare spending in 2005. Long term, the radiation received from a single CT scan of the abdomen/ pelvis has been estimated to cause approximately 12 deaths for every 10,000 scans performed. While other rules for imaging have been developed and implemented in the emergency setting, there is no decision rule to guide the use of appropriate imaging in suspected renal colic. We propose to derive, validate, and test the implementation of a decision rule that will allow appropriate use of CT scan in patients evaluated for suspected renal colic. The derivation set will consist of retrospectively derived data from all patients at our institution over a 4-year period who underwent a CT flank pain protocol (CT FPP) for suspected kidney stone. Classification and regression tree (CART) analysis will be utilized to derive a rule that will reliably predict the presence of kidney stone, as well as stones requiring intervention (6mm or greater), and other urgent or emergent diagnoses likely to require intervention. Once derived, this rule will be prospectively validated using point-of-care clinician performed ultrasound, plain films when appropriate, and data from the electronic medical record. In the final phase the rule will be implemented by physician training and incorporation into the computerized physician order entry (CPOE) system. The performance of the rule will be measured against CT findings and intervention during a 90-day follow-up period. Impact of the rule and cost benefit analysis will be evaluated to determine the comparative effectiveness of the derived rule. We anticipate a rule can be derived and validated, improving patient safety and reducing cost by reducing imaging that will not alter management in suspected renal colic.

Public Health Relevance

CT scanning is increasing, costly and poses a significant public health risk in future radiation induced malignancies. Patients with kidney stones receive multiple CT scans that rarely alter their medical management. This study seeks to identify a subset of patients with suspected kidney stones who may be safely diagnosed and treated without the use of CT scanning, potentially saving both money and lives.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Research Project (R01)
Project #
5R01HS018322-04
Application #
8505332
Study Section
Health Care Technology and Decision Science (HTDS)
Program Officer
Hsia, David
Project Start
2010-08-16
Project End
2014-07-31
Budget Start
2013-08-01
Budget End
2014-07-31
Support Year
4
Fiscal Year
2013
Total Cost
Indirect Cost
Name
Yale University
Department
Emergency Medicine
Type
Schools of Medicine
DUNS #
043207562
City
New Haven
State
CT
Country
United States
Zip Code
06520
Daniels, Brock; Gross, Cary P; Molinaro, Annette et al. (2016) STONE PLUS: Evaluation of Emergency Department Patients With Suspected Renal Colic, Using a Clinical Prediction Tool Combined With Point-of-Care Limited Ultrasonography. Ann Emerg Med 67:439-48
Samim, Mohammad; Goss, Sarah; Luty, Seth et al. (2015) Incidental findings on CT for suspected renal colic in emergency department patients: prevalence and types in 5,383 consecutive examinations. J Am Coll Radiol 12:63-9
Moore, Christopher L; Daniels, Brock; Ghita, Monica et al. (2015) Accuracy of reduced-dose computed tomography for ureteral stones in emergency department patients. Ann Emerg Med 65:189-98.e2
Lukasiewicz, Adam; Bhargavan-Chatfield, Mythreyi; Coombs, Laura et al. (2014) Radiation dose index of renal colic protocol CT studies in the United States: a report from the American College of Radiology National Radiology Data Registry. Radiology 271:445-51
Moore, Christopher L; Bomann, Scott; Daniels, Brock et al. (2014) Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone--the STONE score: retrospective and prospective observational cohort studies. BMJ 348:g2191
Herbst, Meghan K; Rosenberg, Graeme; Daniels, Brock et al. (2014) Effect of provider experience on clinician-performed ultrasonography for hydronephrosis in patients with suspected renal colic. Ann Emerg Med 64:269-76
Moore, Christopher L; Scoutt, Leslie (2012) Sonography first for acute flank pain? J Ultrasound Med 31:1703-11