Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone--the STONE score: retrospective and prospective observational cohort studies

Abstract

Objective: To derive and validate an objective clinical prediction rule for the presence of uncomplicated ureteral stones in patients eligible for computed tomography (CT). We hypothesized that patients with a high probability of ureteral stones would have a low probability of acutely important alternative findings.

Design: Retrospective observational derivation cohort; prospective observational validation cohort.

Setting: Urban tertiary care emergency department and suburban freestanding community emergency department.

Participants: Adults undergoing non-contrast CT for suspected uncomplicated kidney stone. The derivation cohort comprised a random selection of patients undergoing CT between April 2005 and November 2010 (1040 patients); the validation cohort included consecutive prospectively enrolled patients from May 2011 to January 2013 (491 patients).

Main outcome measures: In the derivation phase a priori factors potentially related to symptomatic ureteral stone were derived from the medical record blinded to the dictated CT report, which was separately categorized by diagnosis. Multivariate logistic regression was used to determine the top five factors associated with ureteral stone and these were assigned integer points to create a scoring system that was stratified into low, moderate, and high probability of ureteral stone. In the prospective phase this score was observationally derived blinded to CT results and compared with the prevalence of ureteral stone and important alternative causes of symptoms.

Results: The derivation sample included 1040 records, with five factors found to be most predictive of ureteral stone: male sex, short duration of pain, non-black race, presence of nausea or vomiting, and microscopic hematuria, yielding a score of 0-13 (the STONE score). Prospective validation was performed on 491 participants. In the derivation and validation cohorts ureteral stone was present in, respectively, 8.3% and 9.2% of the low probability (score 0-5) group, 51.6% and 51.3% of the moderate probability (score 6-9) group, and 89.6% and 88.6% of the high probability (score 10-13) group. In the high score group, acutely important alternative findings were present in 0.3% of the derivation cohort and 1.6% of the validation cohort.

Conclusions: The STONE score reliably predicts the presence of uncomplicated ureteral stone and lower likelihood of acutely important alternative findings. Incorporation in future investigations may help to limit exposure to radiation and over-utilization of imaging.

Trial registration: www.clinicaltrials.gov NCT01352676.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: All authors with the exception of BD and SB were funded in part by a research grant from the Agency for Healthcare Research and Quality (5R01HS018322-03); CPG received support from the Robert Wood Johnson clinical scholars program; CLM has received compensation as a consultant from Philips Healthcare and Sonosite (a subsidiary of FujiFilm); CPG is a scientific advisory board member for Fair Health; CPG receives funding from Medtronic as a collaborator on the Yale University Open Data Access project; there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Prevalence of ureteral stone by STONE score category in derivation and validation cohorts. Percentages at top of bars indicate prevalence of ureteral stone in group. Values under bars indicate number within derivation and validation sets that fell within risk stratums