July 29, 2019
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CT scans for patients with hematuria associated with harmful outcomes, increased costs

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Current guidelines for hematuria evaluations that recommend CT scans may increase costs as well radiation-induced cancers, according to a study published in JAMA Internal Medicine.

“Long recognized as a transformative innovation, advanced imaging has come under increased scrutiny,” Mihaela V. Georgieva, PhD, of the department of health policy and management at the University of North Carolina Gillings School of Global Public Health, and colleagues wrote. “Payments for imaging have seen disproportionate growth, and up to half of all imaging studies ordered in the United States may be unnecessary. ... Recommendations for the diagnostic evaluation of hematuria provide an instructive frame of reference within which to consider the advantages, harms and costs associated with CT. Current guidelines emphasize a structured evaluation that includes cystoscopy and imaging to rule out urinary tract malignancy, although the threshold for referral and recommended imaging modality remain uncertain given the limitations in the evidence.”

Researchers evaluated the advantages, harms and costs associated with five guidelines for initial hematuria evaluation. The guidelines considered included Dutch (cystoscopy and ultrasonography for patients 50 years or older), Canadian Urological Association (cystoscopy and ultrasonography for patients 40 years or older), Kaiser Permanente (CT and cystoscopy only for patients with a history of gross hematuria; cystoscopy and ultrasonography for smokers, men and those 50 years and older), Hematuria Risk Index (risk scores calculated: cystoscopy and ultrasonography for moderate risk; cystoscopy and CT for high risk) and the American Urological Association (cystoscopy and CT for all patients 35 years or older).

To assess these guidelines, researchers developed a microsimulation model of 100,000 adults with hematuria aged 35 years or older. Data related to patients’ age, sex and presence of urinary tract cancer were taken from two prospective hematuria cohort studies (n = 6,363 patients). Clinical encounters were simulated, and subsequent outcomes and costs were projected.

The primary outcomes and measures of the study consisted of urinary tract cancer detection rates, radiation-induced secondary cancers due to CT radiation exposure, procedural complications, false-positive rates and incremental cost per additional urinary tract cancer detected.

Of the total cohort, 3,514 patients had urinary tract cancers (estimated prevalence of 3.5%).

CT scan equipment 
Current guidelines for hematuria evaluations that recommend CT scans may increase costs as well radiation-induced cancers.
Source: Adobe Stock

Researchers found that, although the American Urological Association guidelines missed detection for the fewest number of cancers (2.3% vs. 3.3% for Hematuria Risk Index and 3.7% for Kaiser Permanente), there were 575 projected radiation-induced cancers per 100,000 patients under these guidelines compared with 136 and 108 under Hematuria Risk Index and Kaiser Permanente guidelines, respectively.

In addition, although the Canadian Urological Association and Dutch guidelines missed detection for 4.9% and 7.1% of cancers, there were no associated radiation-induced secondary cancers.

Regarding costs, researchers found that the American Urological Association guidelines cost two times more than the other guidelines (eg, $939 per person vs $443 per person with Dutch guidelines) and had an incremental cost of $1,034,374 per urinary tract cancer detected vs. the Hematuria Risk Index guidelines.

“Well-intentioned efforts may lead to the widespread dissemination of clinical practices before their safety and effectiveness are clearly understood,” the researchers concluded. “This model-based comparison of five different guidelines for the diagnostic evaluation of hematuria suggests that, in addition to its substantial costs, the potential harms of the intensive application of uniform CT urography may outweigh the advantages of early diagnosis of urinary tract malignant neoplasms.”

In a related editorial, Scott R. Bauer, MD, ScM, of the University of California, San Francisco, and colleagues wrote: “Certain guidelines-based hematuria evaluations may prioritize decreasing morbidity and mortality from urinary tract cancer but may disregard the harms and costs of the evaluation itself. ... As Georgieva et al have reported, it is possible to rigorously quantify and compare the advantages, harms, and costs of different guidelines-based evaluations, which we hope will encourage the widespread use of guidelines that take a balanced approach to maximizing the net advantage to patients and facilitating high-value care.” – by Melissa J. Webb

Disclosures: Georgieva reports no relevant financial disclosure. Please see the study for all other authors’ relevant financial disclosures.