title: Effect of provider experience on clinician-performed ultrasonography for hydronephrosis in patients with suspected renal colic.
abstract: OBJECTIVE
  Hydronephrosis is readily visible on ultrasonography and is a strong predictor of ureteral stones, but ultrasonography is a user-dependent technology and the test characteristics of clinician-performed ultrasonography for hydronephrosis are incompletely characterized, as is the effect of ultrasound fellowship training on predictive accuracy. We seek to determine the test characteristics of ultrasonography for detecting hydronephrosis when performed by clinicians with a wide range of experience under conditions of direct patient care.
  
  
  METHODS
  This was a prospective study of patients presenting to an academic medical center emergency department with suspected renal colic. Before computed tomography (CT) results, an emergency clinician performed bedside ultrasonography, recording the presence and degree of hydronephrosis. CT data were abstracted from the dictated radiology report by an investigator blinded to the bedside ultrasonographic results. Test characteristics of bedside ultrasonography for hydronephrosis were calculated with the CT scan as the reference standard, with test characteristics compared by clinician experience stratified into 4 levels: attending physicians with emergency ultrasound fellowship training, attending physicians without emergency ultrasound fellowship training, ultrasound experienced non-attending physician clinicians (at least 2 weeks of ultrasound training), and ultrasound inexperienced non-attending physician clinicians (physician assistants, nurse practitioners, off-service rotators, and first-year emergency medicine residents with fewer than 2 weeks of ultrasound training).
  
  
  RESULTS
  There were 670 interpretable bedside ultrasonographic tests performed by 144 unique clinicians, 80.9% of which were performed by clinicians directly involved in the care of the patient. On CT, 47.5% of all subjects had hydronephrosis and 47.0% had a ureteral stone. Among all clinicians, ultrasonography had a sensitivity of 72.6% (95% confidence interval [CI] 65.4% to 78.9%), specificity of 73.3% (95% CI 66.1% to 79.4%), positive likelihood ratio of 2.72 (95% CI 2.25 to 3.27), and negative likelihood ratio of 0.37 (95% CI 0.31 to 0.44) for hydronephrosis, using hydronephrosis on CT as the criterion standard. Among attending physicians with fellowship training, ultrasonography had sensitivity of 92.7% (95% CI 83.8% to 96.9%), positive likelihood ratio of 4.97 (95% CI 2.90 to 8.51), and negative likelihood ratio of 0.08 (95% CI 0.03 to 0.23).
  
  
  CONCLUSIONS
  Overall, ultrasonography performed by emergency clinicians was moderately sensitive and specific for detection of hydronephrosis as seen on CT in patients with suspected renal colic. However, presence or absence of hydronephrosis as determined by emergency physicians with fellowship training in ultrasonography yielded more definitive test results. For clinicians without fellowship training, there was no significant difference between groups in the predictive accuracy of the application according to experience level.
authors.affiliation: Department of Emergency Medicine, University of Connecticut, Hartford Hospital, Hartford, CT.
authors.forename: Meghan K
authors.initials: MK
authors.lastname: Herbst
authors.affiliation: Yale University School of Medicine, New Haven, CT.
authors.forename: Graeme
authors.initials: G
authors.lastname: Rosenberg
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Brock
authors.initials: B
authors.lastname: Daniels
authors.affiliation: Department of Medicine, Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
authors.affiliation: Department of Urology, Yale University School of Medicine, New Haven, CT.
authors.forename: Dinesh
authors.initials: D
authors.lastname: Singh
authors.affiliation: Department of Neurosurgery, Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA.
authors.forename: Annette M
authors.initials: AM
authors.lastname: Molinaro
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT.
authors.forename: Seth
authors.initials: S
authors.lastname: Luty
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT. Electronic address: chris.moore@yale.edu.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Moore
mesh_terms: D002983:Clinical Competence; D005260:Female; D006801:Humans; D006869:Hydronephrosis / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D011446:Prospective Studies; D056844:Renal Colic / Q000000981:diagnostic imaging*; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography