Variation in the Intensity of Hematuria Evaluation: A Target for Primary Care Quality Improvement

Abstract

Background Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients over 35 years. Nonetheless, fewer than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and non-clinical factors associated with evaluation of persons with newly diagnosed hematuria. Methods Retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for non-clinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy and/or abdomino-pelvic imaging within 180 days following hematuria diagnosis. We modeled the association between clinical and non-clinical factors and appropriate hematuria evaluation. Results We identified 2,455 primary care patients 40 years of age or older diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis. 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender and anti-coagulant use (p<0.001, p=0.036, p=0.028). Addition of practice site improved the predictive discrimination of each model (p<0.001). Evaluation was associated with higher rates of genitourinary neoplasia diagnosis. Conclusions Patients with hematuria rarely underwent complete evaluation. While established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions.

The association between symptoms and bladder or renal tract cancer in primary care: a systematic review

“…The studies included a total of 3 451 675 patients and were conducted in the UK, 9,12,13,[16][17][18] the Netherlands, 14,15 Belgium, 8 and the US. 10,11 The reference standards employed in the studies were all follow-up. Table 2 summarises the risk-of-bias and applicability assessments for each of the included studies.…”

“…Eleven of these 56 papers were included in this review, [8][9][10][11][12][13][14][15][16][17][18] while 45 were excluded for the following reasons: narrative review (n = 15); patients, setting, or outcomes did not meet the inclusion criteria (n = 29); and not enough information available to ascertain relevance (n = 1).…”

The NICE primary care referral guideline for suspected bladder or renal cancer

“…11 Overall, the meta-analysis included data from five studies with a total of 70 330 patients, 3,4,[6][7][8] and showed that the PPV of visible haematuria for bladder or renal cancer was 5.1% (95% CI 3.2-8%). Such an overall estimate, derived from studies with age inclusion criteria spanning 15-100 years, is of limited use without at least subgroup analyses examining the effect of known risk factors, such as age and gender.…”

“…The studies were conducted in the UK, 4,7,8,[11][12][13] the Netherlands, 9,10 Belgium 3 and the USA. 5,6 Follow-up was employed as a reference standard in all of the studies. Quality issues noted included: (1) patient selection was not clearly consecutive or random in four of the studies; 5,9,11-13 (2) five of the studies were not conducted in a setting directly representative of UK-based primary care; 3,5,6,9,10 (3) missing data; 7 (4) restricted and/or short follow-up; 5,6 and (5) underspecified presenting symptoms.…”

“…5,6 Follow-up was employed as a reference standard in all of the studies. Quality issues noted included: (1) patient selection was not clearly consecutive or random in four of the studies; 5,9,11-13 (2) five of the studies were not conducted in a setting directly representative of UK-based primary care; 3,5,6,9,10 (3) missing data; 7 (4) restricted and/or short follow-up; 5,6 and (5) underspecified presenting symptoms. 9 The results Apart from haematuria, the symptom or sign with the highest prevalence in bladder cancer was urinary tract infection (UTI) (17%), and raised inflammatory markers in patients with renal cancer (26%; both in patients aged 60 years or above).…”