Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
J Pediatr Urol. 2018 Dec;14(6):525-531. doi: 10.1016/j.jpurol.2018.04.019. Epub 2018 May 24.
Overuse of computed tomography (CT) in the initial evaluation of children with upper urinary tract calculi (UUTC) has been well documented. Follow-up imaging patterns, however, remain undefined. Sequential imaging following an acute episode of UUTC represents additional opportunity for enacting good imaging stewardship, with the optimal goal to reduce unnecessary radiation exposure and cost while ensuring appropriate follow-up.
We explored nationwide imaging patterns for children following emergency department (ED) evaluations for UUTC, hypothesizing that initial imaging choice and complicated visits for UUTC increase the risk of follow-up CT scans.
Claims from Marketscan (2007-2013), an employer-based dataset of privately insured patients, were used to assess children aged 1-18 years presenting to the ED an acute UUTC event. The primary outcome was any imaging within 90 days. Using logistic regression, odds for follow-up CT or plain film kidney-ureter-bladder/ultrasound (KUB/US) imaging were calculated adjusting for patient demographics, initial imaging modality, need for admission, and return ED visits.
A total of 821 children met the inclusion criteria, of whom 261 (31.8%) received no follow-up imaging. Overall follow-up imaging patterns, including the proportions of children receiving CT scans, KUB/US imaging, or no imaging are shown in the Summary Table. Of the children receiving follow-up imaging, KUB/US was obtained in 363 (65.0%) and CT obtained in 197 (35.0%) children. Risk factors for follow-up CT imaging include hospital admission and return ED visits. Children with ureteral calculi and index US evaluation were more likely to receive KUB/US imaging only at follow-up. For children with ureteral calculi, the median time to first follow-up imaging was 9 days (25th-75th percentiles, 2-26 days).
One-third of all children with follow-up imaging after an acute presentation for UUTC will receive a CT. Up to 28% of children with a ureteral calculus will not receive any follow-up imaging within 3 months of presentation. These findings suggest imaging strategies for children following acute evaluation for nephrolithiasis are suboptimal in two ways. First, children receive potentially unnecessary additional radiation burden, an alarming finding considering the high rates of CT scan in the index evaluation for these children. Second, many children with ureteral calculi fail to receive follow-up imaging to document stone passage.
Our findings identify follow-up imaging as another area for quality improvement within the care of children with UUTC. Clinical pathways directing imaging strategies for pediatric nephrolithiasis should focus on follow-up imaging practices and initial evaluation, especially with for those children presenting with ureteral calculi.
大量研究已证实，在儿童上尿路结石（UUTC）的初始评估中，过度使用计算机断层扫描（CT）的情况较为普遍。然而，后续的影像学模式仍未明确。对于 UUTC 急性发作的患者，在后续治疗中进行影像学检查是另外一次实施良好影像学管理的机会，其最佳目标是在确保适当随访的同时，减少不必要的辐射暴露和费用。
我们研究了全美范围内儿童在急诊科（ED）接受 UUTC 评估后的影像学模式，假设初始影像学检查的选择和 UUTC 的复杂就诊会增加后续 CT 扫描的风险。
使用 Marketscan（2007-2013 年）的索赔数据，该数据集是私人保险患者的雇主基础数据集，用于评估年龄在 1-18 岁之间因急性 UUTC 事件就诊 ED 的儿童。主要结局是在 90 天内的任何影像学检查。使用逻辑回归，调整患者的人口统计学特征、初始影像学方式、住院需求和 ED 复诊情况，计算后续 CT 或平片肾-输尿管-膀胱/超声（KUB/US）影像学检查的可能性。
共有 821 名儿童符合纳入标准，其中 261 名（31.8%）未接受任何后续影像学检查。表中显示了总体后续影像学模式，包括接受 CT 扫描、KUB/US 影像学检查或未接受影像学检查的儿童比例。在接受后续影像学检查的儿童中，KUB/US 检查 363 例（65.0%），CT 检查 197 例（35.0%）。后续 CT 影像学检查的危险因素包括住院和 ED 复诊。患有输尿管结石且初始 US 检查的儿童更有可能仅在后续检查中接受 KUB/US 检查。对于患有输尿管结石的儿童，首次后续影像学检查的中位时间为 9 天（25 百分位至 75 百分位，2-26 天）。
在 UUTC 急性发作后接受随访影像学检查的所有儿童中，有三分之一将接受 CT 检查。在 3 个月内，28%的输尿管结石患儿未接受任何后续影像学检查。这些发现表明，在儿童急性肾结石评估后，影像学策略存在两个不足之处。首先，儿童可能会接受不必要的额外辐射，考虑到这些儿童在指数评估中 CT 扫描的高比例，这是一个令人震惊的发现。其次，许多患有输尿管结石的儿童未能接受后续影像学检查以记录结石排出情况。
我们的研究结果表明，在 UUTC 儿童的护理中，随访影像学检查是另一个需要改进质量的领域。指导小儿肾结石影像学策略的临床路径应重点关注随访影像学检查和初始评估，尤其是那些患有输尿管结石的儿童。
