Department of Emergency Medicine, University of Chicago Medicine, Chicago, IL, USA.
Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA.
Am J Emerg Med. 2023 Dec;74:41-48. doi: 10.1016/j.ajem.2023.09.025. Epub 2023 Sep 20.
Non-contrast computed tomography (NCCT) is the gold standard for nephrolithiasis evaluation in the emergency department (ED). However, Choosing Wisely guidelines recommend against ordering NCCT for patients with suspected nephrolithiasis who are <50 years old with a history of kidney stones. Our primary objective was to estimate the national annual cost savings from using a point-of-care ultrasound (POCUS)-first approach for patients with suspected nephrolithiasis meeting Choosing Wisely criteria. Our secondary objectives were to estimate reductions in ED length of stay (LOS) and preventable radiation exposure.
We created a Monte Carlo simulation using available estimates for the frequency of ED visits for nephrolithiasis and eligibility for a POCUS-first approach. The study population included all ED patients diagnosed with nephrolithiasis. Based on 1000 trials of our simulation, we estimated national cost savings in averted advanced imaging from this strategy. We applied the same model to estimate the reduction in ED LOS and preventable radiation exposure.
Using this model, we estimate a POCUS-first approach for evaluating nephrolithiasis meeting Choosing Wisely guidelines to save a mean (±SD) of $16.5 million (±$2.1 million) by avoiding 159,000 (±18,000) NCCT scans annually. This resulted in a national cumulative decrease of 166,000 (±165,000) annual bed-hours in ED LOS. Additionally, this resulted in a national cumulative reduction in radiation exposure of 1.9 million person-mSv, which could potentially prevent 232 (±81) excess cancer cases and 118 (±43) excess cancer deaths annually.
If adopted widely, a POCUS-first approach for suspected nephrolithiasis in patients meeting Choosing Wisely criteria could yield significant national cost savings and a reduction in ED LOS and preventable radiation exposure. Further research is needed to explore the barriers to widespread adoption of this clinical workflow as well as the benefits of a POCUS-first approach in other patient populations.
非增强计算机断层扫描（NCCT）是急诊科（ED）肾结石评估的金标准。然而，明智选择指南建议对于<50 岁且有肾结石病史的疑似肾结石患者，避免进行 NCCT 检查。我们的主要目标是估计在符合明智选择标准的疑似肾结石患者中，采用即时超声（POCUS）优先方法的全国年度成本节省。我们的次要目标是估计 ED 住院时间（LOS）的减少和可预防的辐射暴露。
我们使用 ED 就诊肾结石的频率和 POCUS 优先方法的适用性的现有估计值创建了蒙特卡罗模拟。研究人群包括所有诊断为肾结石的 ED 患者。基于我们模拟的 1000 次试验，我们估计了这种策略避免高级成像的全国成本节省。我们应用相同的模型来估计 ED LOS 和可预防的辐射暴露减少。
使用该模型，我们估计采用 POCUS 优先方法评估符合明智选择指南的肾结石，每年可节省 1650 万美元（±210 万美元），避免 159000 次（±18000 次）NCCT 扫描。这导致全国 ED LOS 减少了 166000 次（±165000 次）。此外，这导致全国每年的辐射暴露减少了 190 万个人剂量当量，这可能每年预防 232 例（±81 例）额外癌症病例和 118 例（±43 例）额外癌症死亡。
如果广泛采用，疑似肾结石且符合明智选择标准的患者采用 POCUS 优先方法可能会带来显著的全国成本节省，减少 ED LOS 和可预防的辐射暴露。需要进一步研究以探索广泛采用这种临床工作流程的障碍，以及 POCUS 优先方法在其他患者人群中的益处。
