1 Center for Evidence-Based Imaging, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.
2 Department of Radiology, Brigham and Women's Hospital, Boston, MA.
AJR Am J Roentgenol. 2019 Jan;212(1):142-145. doi: 10.2214/AJR.18.19966. Epub 2018 Nov 7.
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.
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.
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 = 0.03) 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).
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.
本研究旨在评估基于当地最佳实践制定的肾绞痛适当使用标准（AUC）作为电子临床决策支持（CDS）对疑似肾结石患者急诊科（ED）使用 CT 的影响。
这是一项回顾性队列研究，在一级创伤中心（研究地点）和当地可比医院（对照地点）的 ED 进行。由跨学科的急诊医学、急诊放射科和泌尿科团队制定了一个针对有单纯性肾结石病史且表现为肾绞痛的年轻患者（<50 岁）的 AUC，并将其嵌入 CDS。AUC 一致的输尿管 CT 请求不会收到 CDS 警报。否则，系统会提醒医嘱者考虑进行症状控制或在无 CT 的情况下出院。自然语言处理工具挖掘了 2010 年 9 月至 2012 年（AUC 实施前）和 2013 年 4 月至 2014 年 9 月（实施后 1 年）ED 记录中的就诊信息，以获取腰部压痛或肾或输尿管疼痛的概念唯一标识符。手动审查排除不合格病例；其余病例由多学科团队进行审查。使用卡方检验评估 CT 率差异，这是主要结果。
最终样本包括 AUC 实施前的 467 例患者（194 例为研究地点）和实施后的 306 例患者（88 例为研究地点）。在 AUC 实施后，研究地点的输尿管 CT 率从 23.7%（46/194）下降到 14.8%（13/88）（p=0.03）。对照地点的比率保持不变，分别为 49.8%（136/273）和 48.2%（105/218）（p=0.3）。
基于当地最佳实践制定的 AUC 并将其作为 CDS 实施可能会有效地抑制 ED 中部分肾绞痛患者潜在的过度影像学检查，这些患者不太可能出现复杂的病程或其他危险的诊断。
