Hematuria evaluations based on guidelines that recommend computed tomography (CT) scanning potentially result in excess harm and costs, according to the authors of a new study published in JAMA Internal Medicine.
In a simulated model of 100,000 adult patients with hematuria, 3514 (3.5%) had urinary tract cancers, including bladder cancer, renal cell carcinoma, and upper tract urothelial carcinoma, Matthew Nielsen, MD, MS, of the University of North Carolina at Chapel Hill, and colleagues reported. Guidelines from the American Urological Association (AUA) detected the most cancers (97.7%), whereas guidelines from the Hematuria Risk Index (HRI), Kaiser Permanente (KP), Canadian Urological Association (CUA) and the Dutch detected 96.7%, 96.3%, 95.1%, and 92.9%, respectively.
CT’s ability to miss fewer cancers was offset by its radiation exposure, the study found. According to model projections, radiation-induced secondary cancers from CT would occur in 575 cases per 100,000 with an AUA approach, compared with 136 under HRI guidelines and 108 under Kaiser Permanente recommendations.
The investigators simulated clinical encounters and sequelae under each of the 5 guidelines. With regard to AUA guidelines, all patients aged 35 years or older with hematuria received cystoscopy and CT urography. Under the KP guidelines, only patients with a history of gross hematuria received CT and cystoscopy. Smokers, male patients and those aged 50 years or older received cystoscopy and ultrasonography. Nonsmoking female patients younger than 50 years did not undergo any evaluation. For the HRI guidelines, the investigators calculated HRI scores for each patient to determine their evaluation method: none for low-risk, cystoscopy and ultrasonography for moderate-risk, and cystoscopy and CT for high-risk patients. Under CUA and Dutch guidelines, those aged 40 or older or 50 or older, respectively, received just cystoscopy and ultrasonography.
With respect to cost, uniform use of CT such as recommended by the AUA would cost $939 per person vs $443 per person under Dutch guidelines. Detecting 1 urinary tract cancer would cost an incremental $1,034,374 under a universal approach.
“The balance of harms, advantages, and costs of hematuria evaluation may be optimized with risk stratification and more selective application of diagnostic testing in general and computed tomography imaging in particular,” Dr Nielsen and his team stated.
In an accompanying editorial, Scott R. Bauer, MD, ScM, Veterans Affairs in San Francisco, and colleagues commented that “the best available evidence suggests that uniform use of CT for the initial evaluation of microscopic hematuria is ill advised and should be replaced with risk-based approaches and increased use of renal ultrasonography. Furthermore, all guidelines should consider harms, costs, and advantages.”
Georgieva MV, Wheeler SB, Erim D, et al. Comparison of the harms, advantages, and costs associated with alternative guidelines for the evaluation of hematuria. [Published online July 29, 2019] JAMA Intern Med. doi:10.1001/jamainternmed.2019.2280
Bauer SR, Carroll PR, Grady D, et al. Hematuria practice guidelines that explicitly consider harms and costs. [Published online July 29, 2019] JAMA Intern Med. doi:10.1001/jamainternmed.2019.2269