DOSE. Dose Optimization in Stone Evaluation:

Transcription

1 Dose Optimization in Stone Evaluation: DOSE October 21st 2017 Chris Moore MD Associate Professor, Department of Emergency Medicine Yale University School of Medicine

2 Disclosures I am currently funded by the Agency for Healthcare Research and Quality (AHRQ) under R18HS Minimizing unnecessary irradiation from renal colic CT scans in the United States We are collaborating with Philips Healthcare on research regarding automated image recognition We have equipment loaned from GE and BK Medical for research collaborations

3 You can observe a lot by just watching Yogi Berra

4 2001

5 2017

6 Case 37 y.o. white male, no past medical history, presents with acute onset of right flank pain and vomiting. Urine is clear but dip shows hematuria. He is getting fluids, toradol, morphine, and zofran. Imaging?

7 Urinary Stone Disease Common: 1 in 11 people, increasing in U.S. and worldwide Recurrent: >50% will recur within 5y Is an ED dx: >1M dx per year; >2M visits per year for flank pain concern for renal colic Painful: worse than labor Expensive: ~$10B in annual costs Lots of CT: 70% of USD get CT Controversial: dx and management

8 CT for Kidney Stone 8

9 Smith article, Ann Emerg Med. 2011;58:

10 Is CT helping? 10

11 cost-effectiveness and the R word Comparative effectiveness vs. Cost effectiveness 11

12 cancer risk 12

13 S.T.O.N.E. Score Sex Male +2 Timing <6h h +1 Origin non-black +3 Nausea Nausea alone +1 With vomiting +2 Erythrocytes any blood on UA dip Moore et al. BMJ 2013;5:470-8.

14 S.T.O.N.E. Score Sex Male +2 Timing <6h h +1 Origin non-black +3 Nausea Nausea alone +1 With vomiting +2 Erythrocytes any blood on UA dip Moore et al. BMJ 2013;5:470-8.

15 S.T.O.N.E. PLUS (point-of-care limited ultrasound) 15 Accepted, in revision, Ann EM.

16 An Imaging Algorithm 16

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18 Hydro - Training 18 Herbst et al., Ann Emerg Med 2014;64:

19 Dose Variation in Renal Colic CT 49,903 CTs from Dose Index Registry Low dose defined as <3mSv 2% of CT Renal Colic low dose (DLP ~200mGy*cm) Average 11.2mSv 19 Lukasiewicz et al., Radiology 2014;271:

20 ACR Dose Index Registry Participants 20

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22 ultra low dose ct ~85% CT radiation dose decrease (~11mSv to ~1.5mSv) Overall sensitivity 90.2%; specificity 98.9% 96.0% sensitive for stones requiring 90d intervention 22 Moore et al. Ann Emerg Med 2015;65:

23 AUA 23

24 ACR 24

25 ACEP and ACR 25

26 D.ose O.ptimization in S.tone E.valuation AHRQ Funded 5 year R18 Working through ACR Dose Index Registry Education through RadIQ Stratified delayed randomization trial at institutional level 26

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30 DOSE Intervention 30

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32 Emergency Medicine Perspective More concerned with time More concerned with bad things Less (but not unconcerned) with ultimate course as long as can be discharged safely Fighting cultural norm of all first time renal colic needs a CT Would rather not deal with incidental findings 32

33 First Time renal colic 33

34 First Time renal colic 34

35 Bad Things 35

36 Bad things Back pain or flank pain and no pyuria 36 Moore et al. Acad Emerg Med 2013;5:470-8.

37 Bad things 2.8% with BP/FP no pyuria 37 Moore et al. Acad Emerg Med 2013;5:470-8.

38 Incidental Findings Prevalence of 12.7% (95% CI %) 1 in 8 CT Renal Colic will have in incidental finding with follow-up imaging recommended

39 Incidental Findings Incidentalomas 39

40 DOSE and Best Practice Guideline for Imaging Multi-specialty issue The evaluating clinician: 3 from ACEP The imaging specialist: 3 from ACR The interventionist: 3 from AUA 40

41 What is the optimal diagnostic imaging strategy for different types of patients presenting with pain suspected to be renal colic? I. First time kidney stone: What is the optimal diagnostic imaging strategy for a patient presenting with a first episode of suspected renal colic? II. Recurrent kidney stone: Should imaging differ for patients with recurrent kidney stone and suspected renal colic? II. Special Patient Populations: How should imaging differ in special populations (pregnant, pediatric, obese patients) with suspected renal colic? 41

42 Take Home: Patient-centered care: right test; right patient

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61 incidental findings 61

62 incidental findings 62