Impact of a Health Information Technology-Enabled Appropriate Use Criterion on Utilization of Emergency Department CT for Renal Colic
Impact of a Health Information Technology-Enabled Appropriate Use Criterion on Utilization of Emergency Department CT for Renal Colic
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DOI：
10.2214/ajr.18.19966
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发表时间：
2019-01-01
影响因子：
5
通讯作者：
Khorasani, Ramin
中科院分区：
文献类型：
--
作者：
Raja, Ali S.;Pourjabbar, Sarvenaz;Khorasani, Ramin
objective.本研究的目的是评估基于当地最佳实践的肾绞痛适当使用标准（AUC）的影响，作为电子临床决策支持（CDS），对急诊科（艾德）使用CT疑似肾结石患者。这项回顾性队列研究在一级创伤中心（研究中心）和当地可比医院（对照中心）的急诊室进行。年龄小于50岁、有无并发症肾结石病史、表现为肾绞痛的患者的AUC由跨学科急诊医学、急诊放射学和泌尿学团队开发，并嵌入CDS。AUC一致的输尿管CT请求未收到CDS警报。否则，提醒订购者考虑进行症状控制试验或出院时不进行CT。自然语言处理工具挖掘2010年9月至2012年2月（AUC实施前）和2013年4月至2014年9月（实施后1年）访视的艾德记录，以获得侧腹压痛或肾或输尿管疼痛的概念唯一标识符。手动审查排除了不合格的病例;其他病例由多学科团队审查。卡方检验用于评估CT率差异，主要结局。最终样本包括AUC实施前的467例患者（194个研究中心）和AUC实施后的306例患者（88个研究中心）。实施AUC后，研究中心的输尿管CT率从23.7%（46/194）降至14.8%（13/88）（p = 0.63）。对照部位的发生率保持不变，分别为49.8%（136/273）和48.2%（105/218）（p = 0.3）。根据当地最佳实践实施AUC作为CDS，可有效抑制肾绞痛艾德患者亚组中潜在的成像过度使用，这些患者不太可能有复杂的病程或替代危险诊断。
OBJECTIVE. The purpose of this study was to evaluate the impact of an appropriate use criterion (AUC) for renal colic based on local best practice, implemented as electronic clinical decision support (CDS), on the emergency department (ED) use of CT for patients with suspected nephrolithiasis.MATERIALS AND METHODS. This retrospective cohort study was performed in the EDs of a level I trauma center (study site) and local comparable hospital (control site). An AUC for patients younger than 50 years with a history of uncomplicated nephrolithiasis presenting with renal colic was developed by an interdisciplinary emergency medicine, emergency radiology, and urology team and embedded as CDS. AUC-consistent CT of ureter requests received no CDS alert. Otherwise, the orderer was alerted to consider a trial of symptomatic control or discharge without CT. A natural language processing tool mined ED notes for visits in September 2010-February 2012 (before AUC implementation) and April 2013-September 2014 (1 year after implementation) for concept unique identifiers of flank tenderness or renal or ureteral pain. Manual review excluded noneligible cases; the others were reviewed by a multidisciplinary team. Chi-square tests were used to assess for CT rate differences, the primary outcome.RESULTS. The final sample included 467 patients (194 study site) before and 306 (88 study site) after AUC implementation. The study site's CT of ureter rate decreased from 23.7% (46/194) to 14.8% (13/88) (p = 0.63) after implementation of the AUC. The rate at the control site remained unchanged, 49.8% (136/273) versus 48.2% (105/218) (p = 0.3).CONCLUSION. Implementing an AUC based on local best practice as CDS may effectively curb potential imaging overuse in a subset of ED patients with renal colic unlikely to have a complicated course or alternative dangerous diagnosis.