Identifying Unnecessary Irradiation of Patients with Suspected Renal Colic

描述（由申请人提供）：识别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%的人可能在其一生中经历一次肾绞痛发作，其中许多人将前往急诊科（ED）进行评估。计算机断层扫描（CT）现在是一线检查的怀疑肾绞痛，是准确的检测结石。然而，CT扫描涉及大量的电离辐射，费用昂贵，可能导致进一步的不必要的检查，并且很少改变治疗，因为大多数肾结石会自发消失。在过去的几十年里，CT扫描在美国急剧增加，从1980年的大约300万次扫描到2007年的6000多万次。2000年，每100人扫描约12次，2005年几乎翻了一番，达到每100人扫描约22次；在此期间，用于成像的医疗保险支出从62亿美元增加到120亿美元，占2005年全部医疗保险支出的23%。据估计，从长期来看，每进行1万次腹部/骨盆CT扫描，就会造成约12人死亡。虽然在紧急情况下已经制定和实施了其他影像学规则，但没有决策规则来指导在疑似肾绞痛时使用适当的影像学。我们建议推导、验证和测试一项决策规则的实施，该规则将允许在评估疑似肾绞痛的患者中适当使用CT扫描。衍生集将包括我们机构4年来所有因疑似肾结石而接受CT侧腹疼痛检查（CT FPP）的患者的回顾性数据。分类和回归树（CART）分析将用于得出一个规则，该规则将可靠地预测肾结石的存在，以及需要干预的结石（6mm或更大），以及其他可能需要干预的紧急或紧急诊断。一旦导出，该规则将使用现场临床医生进行的超声波、适当时的平片和电子病历数据进行前瞻性验证。在最后阶段，该规则将通过医生培训和纳入计算机医嘱输入（CPOE）系统来实施。在90天的随访期间，将根据CT检查结果和干预措施来衡量该规则的效果。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。我们期望一个规则可以推导和验证，提高患者的安全性和降低成本，通过减少影像学，不会改变对疑似肾绞痛的管理。

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.