Comparison of the Harms, Advantages, and Costs Associated With Alternative Guidelines for the Evaluation of Hematuria

Abstract

Importance: Existing recommendations for the diagnostic testing of hematuria range from uniform evaluation of varying intensity to patient-level risk stratification. Concerns have been raised about not only the costs and advantages of computed tomography (CT) scans but also the potential harms of CT radiation exposure.

Objective: To compare the advantages, harms, and costs associated with 5 guidelines for hematuria evaluation.

Design, setting, and participants: A microsimulation model was developed to assess each of the following guidelines (listed in order of increasing intensity) for initial evaluation of hematuria: Dutch, Canadian Urological Association (CUA), Kaiser Permanente (KP), Hematuria Risk Index (HRI), and American Urological Association (AUA). Participants comprised a hypothetical cohort of patients (n = 100 000) with hematuria aged 35 years or older. This study was conducted from August 2017 through November 2018.

Exposures: Under the Dutch and CUA guidelines, patients received cystoscopy and ultrasonography if they were 50 years or older (Dutch) or 40 years or older (CUA). Under the KP and HRI guidelines, patients received different combinations of cystoscopy, ultrasonography, and CT urography or no evaluation on the basis of risk factors. Under the AUA guidelines, all patients 35 years or older received cystoscopy and CT urography.

Main outcomes and measures: Urinary tract cancer detection rates, radiation-induced secondary cancers (from CT radiation exposure), procedural complications, false-positive rates per 100 000 patients, and incremental cost per additional urinary tract cancer detected.

Results: The simulated cohort included 100 000 patients with hematuria, aged 35 years or older. A total of 3514 patients had urinary tract cancers (estimated prevalence, 3.5%; 95% CI, 3.0%-4.0%). The AUA guidelines missed detection for the fewest number of cancers (82 [2.3%]) compared with the detection rate of the HRI (116 [3.3%]) and KP (130 [3.7%]) guidelines. However, the simulation model projected 108 (95% CI, 34-201) radiation-induced cancers under the KP guidelines, 136 (95% CI, 62-229) under the HRI guidelines, and 575 (95% CI, 184-1069) under the AUA guidelines per 100 000 patients. The CUA and Dutch guidelines missed detection for a larger number of cancers (172 [4.9%] and 251 [7.1%]) but had 0 radiation-induced secondary cancers. The AUA guidelines cost approximately double the other 4 guidelines ($939/person vs $443/person for Dutch guidelines), with an incremental cost of $1 034 374 per urinary tract cancer detected compared with that of the HRI guidelines.

Conclusions and relevance: In this simulation study, uniform CT imaging for patients with hematuria was associated with increased costs and harms of secondary cancers, procedural complications, and false positives, with only a marginal increase in cancer detection. Risk stratification may optimize the balance of advantages, harms, and costs of CT.

Figure 1.. Cost-effectiveness Efficiency Frontier for Hematuria Guidelines Under Consideration

AUA indicates American Urological Association; CUA, Canadian Urological Association; HRI, Hematuria Risk Index; and KP, Kaiser Permanente.

Figure 2.. Cost-effectiveness Acceptability Curves (CEACs) of Initial Evaluation of Hematuria From a US Medicare Payer Perspective

Each CEAC represents the probability that a strategy is cost-effective under different willingness-to-pay (WTP) thresholds for an additional hematuria-associated urinary tract cancer case detected. No commonly accepted cost-effectiveness threshold exists against which to compare the incremental cost-effectiveness ratios expressed as incremental cost per additional urinary tract cancer detected; therefore, a wide range of possible WTP thresholds was plotted. AUA indicates American Urological Association; CUA, Canadian Urological Association; HRI, Hematuria Risk Index; and KP, Kaiser Permanente.