Eric Lange sprawled out on his couch Aug. 27, in pain and drenched in sweat.

Having had kidney stones 10 years earlier, the 40-year-old Bend man suspected they were paying him another visit. Recurrences are common among kidney stone sufferers.

By 3 a.m. the next morning, the pain was too much. He drove himself to St. Charles Bend’s emergency room.

“I was thinking, ‘Something really serious is going on here,’” he said.

When he got in the room with the doctor, they talked about his previous bout of kidney stones. She said this sounded like kidney stones again. Lange said he told the doctor his high-deductible insurance policy wouldn’t cover much of his bill and asked for the least expensive test possible. The doctor opted for a computed tomography — or CT — scan, which since the mid-1990s has been far and away the most widely used test to diagnose kidney stones.

In many parts of the country, there wouldn’t be much of a cost difference between a CT scan or an ultrasound, the other test doctors use to diagnose kidney stones. According to Healthcare Bluebook, a website that shows recommended prices for health care services, the typical cost of an abdominal CT scan is $333 in Central Oregon; for an ultrasound, it’s $256.

At St. Charles, however, the difference is significant. The health system charges nearly $2,800 for a CT scan of the urinary tract to detect kidney stones, while an ultrasound for the same purpose would cost between $398 and $568. (The actual cost to patients is typically lower because insurance covers a portion.)

No one from St. Charles was made available to explain the price difference between the two scans.

It costs roughly five times more to buy a CT machine than it does ultrasound equipment, so providers typically charge more for CT scans to recoup those costs, said Dr. Steven Michel, a radiologist with Central Oregon Radiology Associates, who couldn’t comment on St. Charles’ prices.

“If you run a rental car agency and you’re renting Kias you’d charge something, and if you were going to rent a Porsche, you’d charge more,” he said.

Lange disputed his bill with the hospital. St. Charles responded in a Nov. 12 letter that it was performing a review of his care that will be completed Dec. 23. Lange said he feels like St. Charles sees him as a blank check.

“I know they have to get their money out of their million-dollar machines, I understand that,” he said. “But are you going to do it by taking advantage of the people who have less money than you in the first place?”

For their part, two emergency physicians interviewed for this article who work at St. Charles hospitals said they don’t even know how much the tests cost.

“As an ER doc, that’s not something I really get into,” said Dr. Mark Goodman, director of the emergency ultrasound program for St. Charles Medical Group and an emergency physician in St. Charles’ Redmond, Madras and Prineville emergency rooms. “My primary goal is using the right test for the patient and being sure that I’m working in the best interest of the patient after talking with them about the risks and benefits of the test.”

Reducing radiation exposure

Doctors most commonly opt for CT scans for diagnosing kidney stones because they offer the clearest picture inside the ureter, the skinny tube that carries urine from the kidneys to the bladder. In a patient with kidney stones, hard mineral deposits form in the kidneys and travel through the ureter to the bladder.

The sensitivity difference between the two tests — the amount of stones they actually find — is stark. Michel, the radiologist, said he estimates ultrasounds are probably between 25 and 50 percent sensitive.

“CT is going to be 98 percent sensitive for finding the stone,” he said. “So if you really want to know what it is, that’s the test to get.”

Recent years, however, have seen a national push toward using ultrasounds to diagnose kidney stones, especially in patients younger than 50 years old who have had kidney stones in the past.

Lowering costs is not the main motivation, though — it’s reducing the amount of radiation patients are exposed to. That’s especially true for kidney stone patients, who are likely to have multiple recurrences over their lifetimes.

Ultrasound uses sound waves that bounce off of internal body structures to create images, whereas CT uses radiation-emitting X-ray beams to generate detailed images.

“Repeat stone patients should not have CT scans every time, unless there is a concern that the stone is infected or that it is somehow stuck and going to need intervention,” said Dr. Gillian Salton, an emergency physician with Central Oregon Emergency Physicians who works at St. Charles Bend.

That’s especially true for younger patients for whom radiation is more harmful, Salton said. Radiation causes long-term damage to cells that can develop into cancer years later.

“And so the earlier in your life that you damage that cell, the longer time you have for that cell to later become cancerous,” Salton said. “The younger somebody is, the more you want to limit their radiation exposure.”

Clearer scans, same outcomes

A study in the September 2014 issue of the New England Journal of Medicine found although CT scans have higher sensitivity than ultrasounds when it comes to detecting kidney stones, that didn’t lead to improved outcomes for patients. (Outcomes were measured in things such as serious adverse events, pain scores and emergency department readmissions.)

A big difference between the two groups: Those who received ultrasounds were exposed to half the amount of radiation compared with those who received CT scans, the study found.

Dr. Rebecca Smith-Bindman, a radiology, epidemiology and biostatistics professor at the University of California, San Francisco, said she hopes her study encourages patients — especially if they’ve had kidney stones before — to ask their doctors about ultrasounds.

While CT scans are “incredibly helpful,” Smith-Bindman said, she thinks they’ve been adopted in some areas without good evidence they lead to better outcomes.

“We’re changing what happens to patients by doing CT,” she said. “Are we improving their health or are we just doing a more advanced test and not really helping them? It’s an area where I feel like, ‘Ultrasound is a great test. Why did we switch from that?’”

Study subjects who received CT scans paid an average of $25 more than those who received ultrasounds.

“As a group, there was not a very big difference in cost between the arms,” Smith-Bindman said.

The study uncovered an unintended consequence of using ultrasounds, however: Nearly 41 percent of study participants who received ultrasounds as their first test in emergency rooms also went on to receive CT scans. Smith-Bindman said she’s not exactly sure why some patients received two tests; it could be because doctors were less confident in the ultrasound results and turned to CT for a more definitive answer.

The fact that some patients were scanned again after receiving ultrasounds makes the initial scan less useful, Michel said

“If 40 percent of the people still need another test, are you really going to gain those savings?” he said.

Depends on the patient

The drive to reduce radiation exposure is echoed in a national campaign launched in 2012 by the nonprofit ABIM Foundation called Choosing Wisely, which seeks to draw attention to the harms of overused medical services.

As part of that campaign, the American College of Emergency Physicians is stressing the importance of avoiding CT scans of emergency room patients younger than 50 with known histories of kidney stones.

That’s not always as simple as it sounds. Although kidney stones are mostly benign aside from what’s often excruciating pain, their symptoms mimic those of life-threatening conditions, such as an aortic aneurysm, which can cause the body’s main artery to burst, or an appendicitis, an inflamed appendix that could rupture.

Kidney stones can also become infected, which leads to infected urine backing up in the kidneys.

That’s why doctors say it’s imperative to rule out those conditions, something a CT scan does best.

Explaining why she performs either a CT or an ultrasound is a daily conversation Salton said she has with patients (and yes, St. Charles Bend does see them daily, she said).

The bottom line is an emergency physician’s job is not to diagnose kidney stones; it’s to rule out a life-threatening condition, she said.

“Our job isn’t to say, ‘You have a kidney stone’; our job is to say, ‘You don’t have an abdominal aortic aneurysm,’ or, ‘You don’t have an appendicitis,’” Salton said, “That is really why CT scans are probably more prevalent than ultrasounds.”

The same test won’t work for every patient. Which one a doctor chooses depends on a patient’s vital signs, laboratory tests and other health conditions as well as whether the patiet has had kidney stones in the past, Goodman said.

“As emergency physicians, we really try to make those diagnostic decisions based on what’s in the best interest of the patient,” he said, “sitting down with the patient and discussing the risks of each test, the information we can get and the benefits of each test.”

— Reporter: 541-383-0304,

tbannow@bendbulletin.com