CT for Renal Colic When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria® Standard template

What Is R-SCAN? Collaborative activity for referring clinicians and radiologists to improve patient care through clinical improvement R-SCAN Collaboration Goals: Ensure patients receive the most appropriate imaging exam at the most appropriate time based on evidence-based appropriate use criteria Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics Lower the cost of care Standard template Intro to what the program is about and its benefits. Website is www.rscan.org Time commitment: staff time dedicated to an R-SCAN project ranges from 15 to 30 hours over a three- to six-month period. You can also gain experience using a clinical decision support (CDS) tool; gaining experience with CDS now will help referring clinicians be prepared for the implementation of federal reimbursement requirements for CDS consultation prior to ordering advanced imaging. This alternative to pre-authorization reduces time and expense for practices and patients when imaging is the next step in the diagnostic process.

Why Participate? R-SCAN Offers: Data-driven system for moving toward value- based imaging and patient care Opportunity to focus on highly relevant imaging exams to improve utilization Collaborators can fulfill their Improvement Activity requirements under the MIPS Easy way to practice with clinical decision support (CDS) technology In preparation for PAMA Free and immediate access to Web-based tools and CME activities Standard template Participants earn improvement activity credits. More here: https://rscan.org/images/PDFs/RSCAN_Improvement-Flyer_v4.Web_09-11-17pdf.pdf Information about Protecting Access to Medicare Act here: https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-April-21-2017-Issue/ACR-Answers-Frequent-Questions-About-CDS-Mandate

Problem: Overuse of CT in ED Cases of Uncomplicated Renal Colic 1 in 11 people in the U.S. get kidney stones and 50% have a recurrence within 5 years, with >2 million ED visits/year [1]. 70% of patients diagnosed with stones receive a CT. CT is used to rule out alternative causes of flank pain. Evidence has shown the rate of acutely important findings not related to ureteral stones on CT is very low, especially in absence of infection or pyuria, with no marked changes in management or outcomes [2, 3, 4]. CT scans lead to increased radiation exposure to the patient and population at large. Overuse of CT scans can result in increased time and cost for both the healthcare system and the patient. The problem statement More information on the issue here: Moore CL, Bomann S, Daniels B, et al. Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone—the STONE score: retrospective and prospective observational cohort studies. BMJ. 2014;348:g2191. Moore CL, Daniels B, Singh D, Luty S, Molinaro A. Prevalence and clinical importance of alternative causes of symptoms using a renal colic computed tomography protocol in patients with flank or back pain and absence of pyuria. Acad Emerg Med. 2013;20(5):470-8. Westphalen AC, Hsia RY, Maselli JH, Wang R, Gonzales R. Radiological Imaging of Patients with Suspected Urinary Tract Stones: National Trends, Diagnoses, and Predictors. Acad Emerg Med. 2011;18(7): 699–707. Gottlieb RH, La TC, Erturk EN, et al. CT in Detecting Urinary Tract Calculi: Influence on Patient Imaging and Clinical Outcomes. Radiology. 2002;225(2):441-449.

Using Evidence to Guide Imaging Ordering Choosing Wisely campaign Collaborative effort between ABIM Foundation and over 70 medical specialty societies Helps patients and medical professionals avoid wasteful or unnecessary medical tests, treatments, and procedures The American College of Emergency Physicians agrees that CT scans are not necessary in cases of renal colic for patients <50 with symptoms of recurrent kidney stones Standard template Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty society provided recommendations. Learn more: www.choosingwisely.org Topic: http://www.choosingwisely.org/clinician-lists/acep-ct-of-abdomen-and-pelvis-for-ed-patients-under-50/

Using Evidence to Guide Imaging Ordering ACR Appropriateness Criteria® Assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for specific clinical conditions Employs input of physicians from other medical specialties and societies to provide important clinical perspectives Standard template See next slide for more info on the Appropriateness Criteria (AC). 6

ACR Appropriateness Criteria: The Facts 178 clinical imaging topics and over 875 clinical variants  Basic access is free Learn more at acr.org/ac Standard template New AC topics are added annually. 7

ACR Appropriateness Criteria for Flank Pain, Uncomplicated Recurrent Stone Disease Flank pain, uncomplicated recurrent stone disease (AGE 19-50 years old) Not included in the standard ACR AC, this variant was created via collaboration between ACR and the American College of Emergency Physicians. Provides an alternative imaging modality to reduce radiation exposure for younger patients with recurrent kidney stones. Customized template 8

Does the Patient Really Need a CT? CT is unlikely to reveal an alternative diagnosis (other than renal stones) if: Clinical presentation suggests kidney stones Patient is 19-50 years old Patient has history of recurrent stones CT may be appropriate if the patient presents with: Fever (some patients without an infection may present with mild fever, so the degree of fever and results of urinalysis must be taken into account) Pyelonephritis Pyuria Symptoms persist or worsen History of severe obstruction with previous stones Clinical diagnosis is uncertain Customized template 9

STONE Score Clinical scoring system used to predict the likelihood of stones, which is inversely associated with likelihood of an acutely important alternate cause of symptoms. Low (0-5) (≤10% chance of stone) Moderate (6-9) (50% chance of stone) High (10-13) (90% chance of stone) Customized template This score may be used to provide objective data to help balance the cost and risk of performing a CT, a low dose CT, or even to forego a CT. In one study, the prevalence of clinically important alternative diagnoses in the high probability of kidney stones group was less than half of the overall group: 0.3% and 1.6% in the derivation and validation cohorts, respectively. More information: https://www.bmj.com/content/348/bmj.g2191.full 10

CT vs US for Suspected Kidney Stones Gold standard for identifying stones and their size and location, 95% sensitivity Exposure to ionizing radiation Costly May reveal alternative high-risk diagnoses US No ionizing radiation Found to have no significant difference in high-risk diagnoses with complications when compared to CT 70% stone detection rate Reveals hydronephrosis and obstructions Customized template 11

Low Dose CT ACEP and ACR recommend reduced-dose CT if CT is indicated Reduced-dose/low dose defined as <3mSv vs average 11.2mSv (~3 years of natural background radiation) Increases noise, but sensitivity still over 90% Most practices have a low dose CT protocol Customized template Data from the Dose Imaging Registry (part of the American College of Radiology National Radiology of Data Registry: http://www.nrdr.acr.org) indicates that the mean institutional dose for CT for renal colic is still greater than 10 mSv, and reduced dose techniques are rarely used in US hospitals. 12

R-SCAN and Clinical Decision Support CareSelect is a web-based version of the ACR Appropriateness Criteria, comprising over 3,000 clinical scenarios and 15,000 imaging indications CareSelect provides evidence-based decision support for the appropriate utilization of medical imaging procedures R-SCAN participants gain free access to a customized, web-based version of CareSelect, a helpful first step for aligning ordering patterns with appropriate use criteria Standard template One of R-SCAN’s many free tools is the CareSelect CDS product, a digital version of the ACR AC. Specifically, the team uses CDS to rate the value of exams ordered for one of R-SCAN’s Choosing Wisely topics before and after an educational program is carried out. All R-SCAN participants have free access to the web-based tool to explore the AC guidelines for other imaging topics. Consulting CDS will be a requirement for the ordering of advanced imaging for Medicare patients starting in 2019, so R-SCAN provides a good way to check out this technology. 13

Getting Started With R-SCAN rscan.org Standard template To access ACR Select, visit the R-SCAN site and click on “Start your project.” 14

Standard template Log in with an ACR username/password. If you don’t have an ACR username and password, the R-SCAN team can provide one. 15

Standard template Click on “Practice with ACR Select.” 16

Standard template Check out the instructions for how to enter data and then click on the “Enter case data” button to explore the AC guidelines and exam ratings. 17

Standard template Here’s an example: Enter a patient’s age and gender. Select the body area of interest. Search on a clinical indication. Select the indication that’s the best match. Review the appropriateness score and note the associated cost and radiation exposure. Select the exam. 18

R-SCAN Renal Colic Educational Resources Visit: rscan.org Click: Resources Click: Topic-specific Resources Podcast (late July 2018) Imaging Order Simulation activity Materials to share with patients Standard template A library of educational materials is available for each R-SCAN Choosing Wisely topic. 19

R-SCAN Resources With CME Podcast A radiologist and referring physician discuss appropriate image ordering for renal colic; approved for .5 CME Coming late July 2018 Imaging Order Simulation Activity Test your knowledge in selecting the best imaging exam for various indications Free with CME Standard template

Key Points: Talking With Patients For most people, a urine and/or blood test is all that is needed to diagnose kidney stones, along with a health history. If you are 19-50, are displaying typical symptoms but are otherwise healthy, and have had kidney stones before, the likelihood of an alternative diagnosis is extremely low. Ultrasound is cheaper, easier to have done, and uses no ionizing radiation. CT imaging may produce incidental findings, requiring further tests, time, and cost just to confirm they will resolve without specific treatment. CT scans expose you to a strong dose of radiation, which may increase your risk for cancer. In some cases, it’s the same as having about 200 chest x-rays. Customized topic slide When they’re needed, CT scans are very helpful. And the risk from a single scan is very small. But CT scans expose you to a strong dose of radiation. In some cases, it’s the same as having about 200 chest X-rays. Your body can often repair the damage CT scans cause to your tissue—but not always. And when it doesn’t, the damage could lead to cancer. The more times you’re exposed, the greater your risk of cancer. Patient handout: https://rscan.org/images/PDFs/topic_resources/CT-in-Renal-Stone.pdf

Case 1 A 35-year-old woman presents to her general practitioner with complaint of left flank pain for the past 6 hours, associated with nausea. Urinalysis reveals mild microscopic hematuria without signs of infection. She had a similar episode approximately 3 years prior while in Mexico and was told she had passed a renal stone. Questions: What imaging would be most appropriate for this patient? What other questions would you ask? What is the focus of your physical exam? Each template will include a few case examples. Answer: This patient has a past medical history of an uncomplicated renal stone. Color Doppler ultrasound imaging of the kidneys and urinary bladder is the best option for this patient. Ultrasound imaging is relatively inexpensive, sensitive, and does not employ ionizing radiation.

Case 2 An 88-year-old nursing home resident presents with right flank pain and dysuria for 3 days. Questions: What imaging would be most appropriate for this patient? What other questions would you ask? What is the focus of your physical exam? Each template will include a few case examples. Answer: CT imaging of the abdomen and pelvis without contrast (also "CT renal stone protocol") is correct for a patient over the age of 50 with a clinical presentation suggestive of urolithiasis/kidney stones.

Blank slide for radiologist to add custom info Suggested topics for additions

Blank slide for radiologist to add custom info Suggested topics for additions

Summary Not all patients presenting with renal colic require a CT. If the patient is showing symptoms of kidney stones, is 19-50, and has a history of recurrent kidney stones, a CT is highly unlikely to reveal acutely important alternative diagnoses. Ultrasound is a viable alternative to CT in many cases, and is recommended by ACR and ACEP over CT for patients as described in the bullet above. Clinical validation rules, such as the STONE score, can help you ascertain the probability of kidney stones. If a CT is indicated, consider using low dose CT, which is still highly sensitive to kidney stone size and location. Standard template, but content will be customized

Questions?