目的:非对比计算机断层扫描(NCCT)是急诊科(ED)肾结石评估的金标准。然而,明智选择指南建议不要对<50岁有肾结石病史的疑似肾结石患者订购NCCT。我们的主要目标是评估使用现场护理超声(POCUS)-首选方法治疗疑似肾结石患者的国家年度成本节省情况。我们的次要目标是估计ED住院时间(LOS)和可预防的辐射暴露的减少。
方法:我们创建了一个蒙特卡洛模拟,使用现有的估计来评估肾结石的ED就诊频率和POCUS优先方法的资格。研究人群包括所有诊断为肾结石的ED患者。根据我们模拟的1000次试验,我们估计在避免这种策略的先进成像方面节省了国家成本.我们应用相同的模型来估计EDLOS和可预防的辐射暴露的降低。
结果:使用此模型,我们估计POCUS-first方法用于评估肾结石会议选择明智的指南,通过避免每年159,000(±18,000)次NCCT扫描,平均节省(±SD)1650万美元(±210万美元).这导致EDLOS在全国范围内累计减少了166,000(±165,000)的年睡小时。此外,这导致全国辐射暴露累计减少190万人mSv,这可能会预防每年232(±81)例过量癌症病例和118(±43)例过量癌症死亡。
结论:如果广泛采用,对于符合选择明智标准的疑似肾结石患者,采用POCUS-first方法可显著节省国家成本,降低EDLOS和可预防的辐射暴露.需要进一步的研究来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。
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.