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Original Investigation
Less Is More
July 29, 2019

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

Author Affiliations
  • 1Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill
  • 2University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
  • 3Division of eHealth, Quality and Analytics, Social Policy, Health and Economics Research Unit, RTI International, Research Triangle Park, North Carolina
  • 4Departments of Radiology, Epidemiology and Biostatistics, University of California at San Francisco, San, Francisco
  • 5Department of Urology, Kaiser Permanente Southern California, Los Angeles, California
  • 6Department of Urology, Geisinger Health, Danville, Pennsylvania
  • 7Department of Urology, University of North Carolina School of Medicine, Chapel Hill
  • 8Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill
  • 9Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
JAMA Intern Med. 2019;179(10):1352-1362. doi:10.1001/jamainternmed.2019.2280
Key Points

Question  What are the harms, advantages, and costs associated with alternative guidelines for examining patients with hematuria?

Findings  In a microsimulation modeling study of a hypothetical cohort of 100 000 adults with hematuria, uniform computed tomography scanning appeared to be associated with more than 500 secondary cancers from imaging-associated radiation exposure and was approximately twice the cost of alternative approaches.

Meaning  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.


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.

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