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Introduction: We sought to assess the accuracy of using stone volume (SV) estimated with a software algorithm as a predictor for stone passage in a trial of medical expulsive therapy (MET). Methods: We identified patients with ureteral stones discharged from the ER on MET. Patients with infection, non-ureteral stones, or needing immediate surgical intervention were excluded. For each stone, longest dimension (LD) was recorded and SV was estimated by a computed tomography (CT)-based region growing (RG) algorithm and standard ellipsoid formula (EF). Stone passage within 30 days was assessed via electronic chart and followup phone call. Results: Fifty-one patients were included for analysis (53±16.7 years, 24% female). The mean LD was 4.85±2.02 mm. The mean SV was similar by EF and RG (0.051±0.057cm3 vs. 0.049± 0.052 cm3; p=0.28). Thirty-three (65%) patients passed their stone, while 18 (35%) did not. The mean LD for passed stones vs. failed passage was 4.1±1.7 mm vs. 6.2±1.8 mm (p=0.0002); the mean EF volume was 0.028±0.035 cm3 vs. 0.093±0.066 cm3 (p=0.00007); and the mean volume by RG was 0.028±0.027cm3 vs. 0.088±0.063 cm3 (p=0.00005). Conclusions: The clinical utility of using SV estimated by software algorithm as a predictor for success of MET has not previously been examined. We demonstrate that spontaneously passed stones had a significantly smaller volume than those requiring intervention. Further prospective studies are needed to validate these findings and establish volume thresholds for probability of stone passage.

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Methods: The EDIT team designed two evidence-based, provider-focused interventions: 1) an audit-feedback (AU-FB) intervention that provided periodic information on the higher incidence of SAH among Blacks and their lower rates of neuroimaging; and 2) clinical decision support (CDS) embedded in the electronic health record with similar content. These interventions were tested in sequential blinded, randomized, controlled trials; providers were unaware of the study. Attending physicians, emergency medicine residents, and physician assistants working in the adult ED of a large urban academic medical center were randomized to either AU-FB or control. After a 12month intervention period and a 9-month washout period, providers were re-randomized to either CDS or control for another 12-month period. All adult patient visits (age 18), identified through an automated report of patients for whom an adult headache template was used by the ED clinician during the study period, were reviewed. Patients with history of trauma were excluded. Data elements, abstracted by automated reports and structured manual review by trained research staff, included: ED provider names; patient age, sex, race, ethnicity, insurance type, emergency severity index, chief complaint, vital signs, pain score, neuro imaging order, ED disposition, ED diagnosis, and elements of the prior medical history, history of present illness, and physical examination significantly associated with the decision to order diagnostic imaging in a previously reported observational study, which confirmed the presence of a Black-White imaging disparity at the study site. Comorbidities were categorized using the Elixhauser Comorbidity Index. Results: 8,185 ED visits were reviewed; 130 (1.6%) of these were ED revisits within 2 days of a previous ED visit for headache. These were dropped resulting in a final sample of 8,055 visits. The primary outcome for both trials is likelihood of a neuroimaging order for Black vs White patients. Secondary analyses will examine neuroimaging for all racial/ethnic/sex patient groups; comparative effectiveness of the two interventions; provider subgroups (attending, resident, PA); and concordance vs discordance of provider-patient race/ethnicity. Conclusions: The EDIT Trial tested the effectiveness of two provider-focused interventions addressing a racial disparity in diagnostic imaging rates for ED patients with headache. These interventions are particularly timely given current efforts to decrease CT utilization for ED patients with headache.

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