Identifying Unnecessary Irradiation of Patients with Suspected Renal Colic

描述（由申请人提供）：确定疑似肾绞痛患者的不必要照射高达12%的人口患有肾结石，3-5%的人可能在一生中经历肾绞痛发作，其中许多人将到急诊室（艾德）进行评估。计算机断层扫描（CT）扫描现在是怀疑肾绞痛的一线测试，并且在检测结石方面是准确的。然而，CT扫描涉及大量的电离辐射，是昂贵的，可能会导致进一步不必要的测试，很少改变管理，因为大多数肾结石通过自发。在过去的几十年里，CT扫描在美国急剧增加，从1980年的大约300万次扫描增加到2007年的6000多万次。在2000年，每100人约有12次扫描，2005年几乎翻了一番，每100人约有22次;在此期间，医疗保险的成像支出从62亿美元增加到120亿美元，占2005年所有医疗保险支出的23%。从长远来看，腹部/骨盆单次CT扫描的辐射估计每进行10，000次扫描就会造成约12人死亡。虽然已经制定了其他成像规则并在紧急情况下实施，但没有决策规则来指导在疑似肾绞痛中使用适当的成像。我们建议推导、验证和测试一个决策规则的实施，该规则将允许在疑似肾绞痛的患者中适当使用CT扫描。推导集将包括4年内在我们机构接受CT腰痛方案（CT FPP）治疗疑似肾结石的所有患者的回顾性数据。将利用分类和回归树（CART）分析得出一条规则，该规则将可靠地预测肾结石的存在，以及需要干预的结石（6 mm或更大），以及可能需要干预的其他紧急或紧急诊断。一旦得出，将使用床旁临床医生进行的超声、平片（如适用）和电子病历中的数据对该规则进行前瞻性验证。在最后阶段，该规则将通过医生培训和纳入计算机化医嘱输入（CPOE）系统来实施。在90天的随访期内，将根据CT结果和干预措施来衡量该规则的执行情况。将评估规则的影响和成本效益分析，以确定派生规则的相对有效性。我们预计可以得出并验证一个规则，通过减少不会改变疑似肾绞痛治疗的成像，提高患者安全性并降低成本。 公共卫生相关性：CT扫描正在增加，成本高昂，并对未来辐射诱发的恶性肿瘤构成重大公共卫生风险。肾结石患者接受多次CT扫描，很少改变他们的医疗管理。这项研究旨在确定一部分疑似肾结石的患者，他们可以在不使用CT扫描的情况下安全地诊断和治疗，从而可能节省金钱和生命。

DESCRIPTION (provided by applicant): 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.