____________________________________________ A Physicians Survey: Comparing CT versus IVP in the Diagnosis of Hematuria or Renal Colic

Sameer A. Patel, Kamal N. Morar, Michael G. Edwards Department of Radiology Providence Hospital and Medical Center Southfield, MI 48075 _____________________________________
We conducted a pilot study to examine physicians understanding of the diagnostic imaging test of choice in regards to patients presenting with hematuria or renal colic. Participants were asked to complete a survey consisting of eight questions regarding this subject matter. Nine hundred surveys were circulated at several community hospitals in a major metropolitan city and one hundred seventy of them were returned completed between September and November 2002. The physicians were then categorized as Primary Care and Non Primary Care (Specialist) physicians. The physicians were also subcategorized as attending physicians and resident physicians. Thirty-four out of ninety four (36.2%) primary care physicians believed that CT scan was a better diagnostic test than IVP for hematuria. Forty-two of seventy-six (55.3%) non-primary care physicians believed that CT scan was a better diagnostic test than IVP for hematuria. Thirtyseven out of ninety four (39.4%) primary care physicians believed that CT scan was the diagnostic test of choice for renal colic and forty out of seventy-six (52.6%) non-primary care physicians believed CT scan was the test of choice of renal colic. A significant proportion of physicians in this pilot study had misconceptions regarding the diagnostic modality of choice for renal colic and hematuria. The survey also demonstrated misconceptions regarding the differences in cost, radiation exposure, time and level of invasiveness for CT scan and IVP imaging examinations. These misconceptions were held by primary care physicians, specialists, residents and attending physicians. Increased education in regards to diagnostic imaging for renal colic and hematuria is evidently needed in the medical community. Key Words: CT, IVP, Renal Hematuria, Cost, Radiation, Invasive Colic,

2003 The Journal of Radiology

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is a common condition that affects a minimum of 12% of the U.S. population during their lifetime. 1 This medical problem occurs most frequently in men, usually between the ages of 20 and 50 years. 2 It accounts for 96 of 100,000 hospital discharges or 122 of 100,000 outpatient visits per year alone here in the United States. 3 , 4 It often leads to hospitalization 5 and has recurrence rates reaching 50% in ten years. 6 Patients with urolithiasis typically present with severe abdominal, back or loin pain. Other common complaints include nausea, vomiting, flank pain and hematuria. 7 Rapid diagnosis is essential in order to exclude other significant conditions that may present as an acute abdomen and allows for early implementation of treatment modalities. Diagnostic imaging plays a crucial role in initiating this cascade of events and when correctly used, can lead to decreased cost and improved patient care for the involved hospital. Good diagnostic tests aids in clinical decision-making and will improve patient outcomes by providing guidance for therapeutic interventions. Conversely, diagnostic tests that provide no change of patient treatment are of little value and will not change patient outcomes. Although intravenous pyelography (IVP) has been the gold standard for patients presenting with renal colic in the past, unenhanced computed tomography (CT) is gaining widespread acceptance in the medical community. Many studies have shown unenhanced helical CT to be the study of choice in the evaluation of patients with suspected renal colic. 8,9 The benefits of using CT for the evaluation of renal colic or hematuria include increased accuracy, decreased procedure time, no intravenous contrast medium and its associated risk of reaction and the ability to identify other potential causes for the patients flank pain. 10 These facts have been well documented in the literature, however a recent article published in the American

Urolithiasis

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Journal of Radiology (AJR) by Eisenberg and Berlin brought to question whether the medical community was aware of the literature regarding diagnostic imaging for renal colic or hematuria. 11 The article involved a urologist, emergency medicine physician, radiologist and litigation that was brought up over the death of a patient with flank pain from the intravenous contrast medium used during an IVP. The emergency medicine physician consulted the urologist who ordered the IVP despite the radiologists recommendation to use unenhanced CT. This article reveals the issue that many physicians may not be aware of the literature regarding this subject and prompted us to distribute a survey posing questions regarding the use of CT versus IVP for patients presenting with renal colic and hematuria. Questions were also asked regarding the differences in price, radiation exposure, length of examination and level of invasiveness. We hope to gather data demonstrating whether or not more education is needed on this subject and about the benefits and risks of each procedure.

whether the CT scan was with contrast or not. This allowed us to indirectly examine if the participants were aware that CT scans for renal colic or hematuria must be done without contrast in order to better visualize calculi within the kidneys or ureteral system. The question regarding level of radiation exposure of IVP versus CT scans also did not specify whether nephrotomograms were part of the IVP. Nephrotomograms are included routinely when an IVP is ordered at the institutions we surveyed. The questionnaires were collected and the data was compiled as proportions and percentages. The data was subcategorized according to the type of physician who completed it and if they were in training or in practice.

Results
One hundred seventy physicians completed the survey of nine hundred that were distributed at multiple hospital centers in a large metropolitan area over the period of September to November 2002. The results were categorized as specialists and primary care physicians. The primary care group was composed of Family Practice physicians (20/170, 11.8%), Emergency Medicine physicians (12/170, 7.1%) and Internal Medicine physicians (62/170, 36.5%). The specialist physicians were composed of Radiologists (10/170, 5.9%), General Surgeons (28/170, 16.5%), Obstetricians and Gynecologists (8/170, 4.7%), Medical subspecialists (20/170, 11.8%), and Urologists (10/170, 5.9%). The primary care physicians totalled 94/170 (55.3%) of the survey participants, of who 34/94 (36.2%) were residents. The specialists totalled 76/170 (44.7%) of the survey participants, of who 12/76 (15.8%) were residents. One hundred percent of the Radiologists and Medical Specialists were attending physicians. Fifty percent of the ER physicians and Family Practitioners were attending physicians. Seventy one percent of the Internal Medicine physicians were attending physicians. Seventy five percent of the OB/GYN physicians were attending physicians, 78.6% of the General Surgeons were attending physicians and 60% of the Urologists were attending physicians. With regards to hematuria, only 34/94 (36.2 %) primary care physicians and 42/76 (55.3 %) of specialists believed that CT scan was the diagnostic

Methods and Materials

Nine hundred surveys were distributed to various hospitals in a large metropolitan area. The survey consisted of eight questions regarding IVP and CT scans for hematuria and flank pain. (Appendix) There were also additional questions regarding the differences in cost, length of exams, level of invasiveness and dose of radiation from each. The physicians were first asked to identify which field of medicine they were in and whether they were in practice or in training. The following question asked the physician were to choose between CT scan and IVP as an imaging study for a patient with hematuria. They were asked the same question regarding renal colic. The following four questions as previously mentioned then asked about differences in cost, time required for examination, radiation and level of invasiveness. The question regarding level of invasiveness of IVP versus CT scans did not include

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test of choice. Seventy-nine out of ninety four (84%) primary care physicians and 67/76 (88.2%) specialists believed that CT scan was a more expensive imaging technique than IVP. Forty-two out of ninety four (44.7%) primary care physicians and 23/76 (30.3%) specialists believed that CT scan exposed the patient to more radiation than IVP. Eighty-one out of ninety four (86.2%) primary care physicians and 41/76 (53.9%) specialists believed that CT scan was more invasive than IVP when evaluating a patient for renal colic and hematuria. Three out of ninety four (3.2%) primary care physicians and 25/76 (32.9%) specialists believed that CT scan and IVP were equally invasive. Eighty out of ninety-four (85.1%) primary care physicians and 63/76 (82.9%) specialists believed that CT scan was a quicker imaging modality than IVP. Thirty-seven out of ninety four (39.4%) primary care physicians and 40/76 (52.6%) specialists believed that CT scan was the test of choice over IVP for patients presenting with renal colic.

Discussion
Urolithiasis is a common problem for millions of people worldwide. This medical problem accounts for a significant amount of hospital discharges, outpatient visits and hospitalization. This problem can recur and account for repeated visits to inpatient or outpatient centers. The presentation of urolithiasis usually includes abdominal, back, loin or flank pain, and even hematuria. 7 Rapid diagnosis can lead to quicker therapeutic intervention and exclusion of other diagnoses that may mimic these symptoms. The literature clearly demonstrates that unenhanced CT scan is the new imaging exam of choice for patients presenting with symptoms of urolithiasis. A recent prospective study between IVP and unenhanced CT demonstrated that CT scan diagnosed urolithiasis significantly better than IVP. 10 This study showed that IVP was only 94% specific while spiral CT was 100% specific. Yet another study by Yilmaz et al. compared ultrasound, CT and IVP on 97

patients with renal colic. Spiral CT yielded the greatest results with a 94% sensitivity and 97% specificity compared with IVP, which demonstrated a 52% sensitivity, and 94% specificity. 12 Numerous other studies have evaluated and advocate the use of spiral CT for diagnosing acute flank pain. 13, 14, 15 The increased sensitivity and specificity of CT scan over IVP for renal colic, hematuria, and other symptoms of urolithiasis has been well documented. Spiral CT also provides detection of other causes of pain i n the groin or abdomen that may not be related to the kidneys or ureteral system. CT can easily identify appendicitis, diverticulitis, pelvic inflammatory disease, ovarian cysts and even abdominal aortic aneurysm. 16 Another advantage of spiral CT is the ability to detect radiolucent calculi and its ability to differentiate between different compositions of stones. 16, 17 This provides added information that the IVP cannot. A significant amount of the physicians in our study demonstrated a lack of know ledge regarding this subject. IVP was the study of choice for hematuria in 63.8% of the primary care physicians surveyed and 60.6% thought IVP was best for renal colic. Forty four percent of specialists chose IVP for hematuria and 47.4% chose IVP for renal colic. These numbers represent a significant amount of physicians that may order diagnostic imaging tests that are no longer considered the gold standard for symptoms of urolithiasis. The total cost for hospitalization, evaluation and treatment of urolithiasis in the United States alone is estimated to be 1.83 billion dollars. 18 The difference in cost between the aforementioned studies has also been well documented in the literature revealing discrepancies in the data. One study by Mill and Rineer et al. documented that non-contrast CT was more expensive than IVP ($256 versus $92 respectively). 10 The article also documented that the IVP was 240 dollars when nonionic contrast was used. Similar studies support this claim that spiral CT is a more expensive examination than IVP. 19, 20 These studies however made no mention if nephrotomograms were included in the cost analysis of the IVP. We found another study by Rosser and Zagoria that found that an IVP with four nephrotomograms exposed the patient to a greater amount of radiation than helical CT. 21

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This discrepancy in the cost difference between these studies was also reflected by the physicians in our survey. Eighty four percent of primary care physicians and 88.2% of specialists believed that CT scan was a more expensive study. The majority of subjects surveyed believed that CT was the more expensive study demonstrating that knowledge regarding use of nephrotomograms with IVP is also lacking. When CT scan is ordered as the initial diagnostic modality for renal injuries, the number of further tests needed to define the injury is greatly reduced. 22 This reduction in repeat radiographic procedures leads to greater cost-effectiveness and reduction of overall cost to the treating institution. 10, 22 CT also improves clinicians diagnostic confidence resulting in changes in initial treatment plans, procedures ordered and decreases in the need for further imaging and consultation. 23 This also leads to an overall reduction in health care cost despite the difference between each imaging study. This increase in diagnostic confidence also results in a reduction of total time spent in the hospital and decreased admissions. 23 When individually contrasted, CT is proven to be a faster exam than IVP. 17, 20, 21 IVP often requires delayed imaging which can increase the total time of examination. 10 This decrease in length of examination, cost and overall reduction in time spent in the hospital only contributes to the overall cost effectiveness of CT scan over IVP. Most of the primary care physicians (85.1%) and specialists (82.9%) we surveyed correctly believed that CT scan was a quicker exam than IVP. One of the greatest benefits of CT scan over IVP for symptoms of urolithiasis is the fact that CT scan of the kidneys and ureteral system do not require intravenous contrast. IVP requires a contrast medium and carries a risk of nephrotoxicity and systemic reaction including urticaria, bronchospasm, hypotension, anaphylaxis, and death. As previously mentioned, a lawsuit was brought against a radiologist regarding the death of a patient from the IV contrast used during an IVP ordered for renal colic pain. 11 Shockingly, 86.2% of primary care physicians

surveyed and 53.9% of specialists believed that CT scan was more invasive than IVP when evaluating a patient for renal colic and hematuria. Interestingly, 3.2% of primary care physicians and 32.9% of specialists believed that CT scan and IVP were equally invasive. These results show the lack of understanding regarding CT scan examination of the kidneys and ureteral system for symptoms of urolithiasis. Our survey aimed to discover if the medical community was aware of the literature and indications for unenhanced CT scan for patients presenting with hematuria and renal colic. The results we collected demonstrate that a significant proportion of physicians in this pilot study had misconceptions regarding the diagnostic modality of choice for renal colic and hematuria. These misconceptions also included differences in cost, radiation exposure, length of exam and level of invasiveness for CT scan and IVP. These misunderstandings spanned resident and attending physicians in all subspecialties of medicine including Urology, Emergency Medicine and Radiology. We feel a greater emphasis should be placed on education regarding the choice of diagnostic imaging for the various patient presentations of urolithiasis. .

References
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Sierakowski R, Finlayson B, Landes RR, et al. The frequency of urolithiasis in hospital discharge diagnosis in the United States. Invest Urol 1978; 15:438-431. 2 Stewart C. Nephrolithiasis. Emerg Med Clin North Am 1988;6:617-630. 3 Graves EJ: 1991 Summary: national hospital discharge summary. Adv Data Vital Health Stat Natl Center Health Stat, series 13, number 114, 1993. 4 Hiatt RA, Dales LG, Friedman GD, et al: Frequency of urolithiasis in a prepaid medical care program. Am J Epidemiol 115: 255-265, 1982. 5 Juuti M, Heinonen PO. The incidence of urolithiasis leading to hospitalisation in Finland. Acta Med. Scand. 1979; 206:397-403 6 Leusmann DB, Niggemann H, Roth S, et al.: Recurrence rates and severity of urinary calculi. Scand J Urol 154: 20202024, 1995. 7 Li J, Kennedy D, Levine M, Kumar A, Mullen J: Absent Hematuria and expensive computerized tomography: case characteristics of emergency urolithiasis. J of Urol 2001 Mar;165(3):782-4 8 Smith RC, Rosenfield AT, Choe KA, et al. Acute flank pain: comparison of non-contrast enhanced CT and intravenous urography. Radiology 1995; 194:789-794

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Sourtzis S, Thibeau JF, Damry N, Raslan A, Vandendris M, Bellemans M. Radiologic investigation of renal colic: unenhanced helical CT compared with excretory urography. AJR 1999;172:1491-1494 10 Mill OF, Rineer S K, Reichard SR et al. Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain. Urology 1998;52:982-7. 11 Eisenberg RL, Berlin L. Malpractice Issues in Radiology: When does malpractice become manslaughter? AJR August 2002:179:331-335 12 Yilmaz S. Sindel T, Arslan G et al. Renal colic: Comparison of spiral CT, US and IVU in the detection of ureteral calculi. Eur Radiol. 1998;8:212-17 13 Dalrymple NC, Verga M, Anderson KR, et al. The value of unenhanced helical computerized tomography in the management of acute flank pain. J. Urol . 1998;159: 735-40 14 Smith RC, Verga M, McCarthy S, Rosenfield AT. Diagnosis of acute flank pain: Value of unenhanced helical CT. AJR 1996;166:97-101 15 Boridy IC, Nikolaidis P, Kawashima Sandler CM, Goldman SM. Noncontrast helical CT for ureteral stone. World J. Urol . 1998;16:18-21 16 Handrigan MT, Thompson I, Foster M. Diagnostic procedures for the urogenital system. Emerg Med Clin North Am 2001 Aug;19(3):745-61 17 Patel M, Stephen S, Han Y, Vaux K, Saalfeld J, Alexander J. A protocol of early spiral computed tomography for the detection of stones in patients with renal colic has reduced the time to diagnosis and overall management costs . Aust N.Z. J. Surg. 2000 Jan;70(1):39-42 18 Clark JY, Thompson IM, Optenberg IA. Economic impact of urolithiasis in the United States. J Urol . 1995;154:2020-4.

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Thomson JM, Glocer J, Abbot C, Maling TM, Mark S. Computed tomography versus intravenous urography diagnosis of acute flank pain from urolithiasis: a randomized study comparing imaging costs and radiation dose. Australas Radiol 2001 Aug;45(3):291-7 20 Niall O, Russel J, MacGregor R, Duncan H, Mullins J. A comparison of noncontrast computerized tomography with excretory urography in the assessment of acute flank pain. J Urol 1999 Feb;161(2):534-7 21 Rosser CJ, Zagoria R, Dixon R, Scurry WC, Bare RL, McCullough DL, Assimos DG. Is there a learning curve in diagnosing urolithiasis with noncontrast helical computed tomography? Can Assoc Radiol J 2000 Jun;51(3):177-81 22 Erturk E, Sheinfeld J, DiMarco PL, Cockett AT. Renal Trauma: evaluation by computerized tomography. J Urol 1985 Jun;133(6):946-9 23 Abramson S, Walders N, Applegate KE, Gilkeson RC, Robbin MR. Impact in the emergency department of unenhanced CT on diagnostic confidence and therapeutic efficacy in patients with suspected renal colic: a prospective survey. 2000 ARRS Presidents Award. American Roentgen Ray Society. AJR 2000 Dec;175(6):1689-95

Appendix
Q1. What field of medicine are you in? Q2. Are you in practice or in training? Q3. If you consider using IVP or CT scan for hematuria, which one would you order? Q4. Which one do you think costs more? Q5. Which one do you think has higher radiation exposure? Q6. Which one is less invasive? Q7. Which one can be performed quicker? Q8. If you consider using IVP or CT scan for renal colic pain, which one would you order?

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