Evaluating Cost-Effective Strategies for Asymptomatic Microhematuria Diagnosis: A Risk-Based Alternative to the American Urological Association Guidelines

Abstract

Background and objectives: The American Urological Association (AUA) guidelines recommend evaluating asymptomatic microhematuria (MH) at ≥ 3 red blood cells per high powered field (RBCs/hpf), resulting in significant costs with limited bladder cancer detections. This study evaluates alternative diagnostic strategies to improve the cost-effectiveness of asymptomatic MH evaluation.

Methods: The cost-effectiveness analysis compared three alternative strategies: Strategy 1 (cystoscopy at ≥ 26 RBCs/hpf) was compared to a 3 RBCs/hpf threshold, while Strategy 2 (cystoscopy and renal ultrasound at ≥ 3 RBCs/hpf) and Strategy 3 (cystoscopy and renal ultrasound at ≥ 26 RBCs/hpf) were compared to the AUA guidelines. Total costs, cost per patient evaluated, costs per cancer detected, and incremental cost-effectiveness ratios (ICERs) were calculated.

Results: Strategy 3 minimized costs without significantly reducing early cancer detection rates. It was cost-effective for females (ICER = $120,649) and the total sample (ICER = $50,648) but not specifically for males (ICER = $23,326). Strategies 1 and 2 yielded lower cost savings and were less efficient.

Conclusions: Strategy 3-performing cystoscopy and renal ultrasound for higher-risk patients ( ≥ 26 RBCs/hpf)-offers a more cost-effective approach than the AUA guidelines, particularly for women. Future studies should incorporate additional patient variables and diagnostic test characteristics.

Keywords: bladder cancer; cost‐effectiveness; cystoscopy; microhematuria.