2. UroToday Home
  3. Recent Abstracts
  4. Urologic Oncology
  5. Bladder Cancer

Cost-effectiveness of Common Diagnostic Approaches for Evaluation of Asymptomatic Microscopic Hematuria - Beyond the Abstract

Asymptomatic microscopic hematuria (AMH) has a finding’s prevalence of 40.9% of US adults during urinalysis1,2, with 0-11% of that subgroup showing genitourinary (GU) malignant abnormalities3-6. Currently, standard protocols from the American Urology Association (AUA), advocates for diagnostic protocols (computed tomographic (CT) urography and cystoscopy ) that maximally detect occult malignant neoplasm, though most results are negative. However these protocols carry severe adverse events and risks, which impacts quality of life and generates higher health care costs7-12. Few studies have analyzed the cost-effectiveness of AMH evaluation. The primary objective of this study was to determine the relative cost per cancer detected among 4 diagnostic protocols for the evaluation of AMH.  The authors hypothesized that replacement or exclusion of CT from diagnostic protocols would significantly reduce costs with minimal compromise on cancer detection. 

The researchers developed a decision-analytic model-to stimulate cancer detection rates and costs associated with the evaluation of adult patients with ADH. Inclusion criteria were patients having 3 or more red blood cells on urinalysis, no history of GU malignant abnormalities, and concurrent negative urine culture of UTI. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability.  The 4 diagnostic protocols that were looked at were: (1) computed tomography (CT) alone; (2) cystoscopy alone; (3) CT and cystoscopy combined; and (4) renal ultrasound and cystoscopy combined. The main outcomes and measures for this study were termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH.

 The results showed that of the 4 diagnostic protocols, CT alone detected the fewest cancers, 221 per 10,000 patients at a cost of $9,300.000. Cystoscopy detected 222 cancers and was most cost-effective approach in the subgroup analysis with an ICCD of $10,287. Addition of ultrasound with cystoscopy detected an addition 23 cancers at an ICCD of $53, 810 in comparison for the cystoscopy alone group.   Replacing ultrasound with CT detected just 1 additional cancer at an ICCD of $6,480, 484. This model was stable with variation of all inputs across proposed ranges, and was not sensitive to any inputs within the proposed ranges. Probabilistic sensitivity analysis showed that ultrasound and cystoscopy was optimal in 100% of simulations.

Some limitations that the authors noted were the short model horizon, heterogeneity of GU malignant abnormalities, and limited data existed on accuracy of ultrasound for UTUC diagnosis. In conclusion, the combination of renal ultrasound and cystoscopy is the most cost-effective among 4 diagnostic approaches for the evaluation of AMH. Ultrasound should be used as first-line diagnostic strategy due to optimization of cancer detection and reduction of costs associated with evaluation of AMH. These findings show the need to evaluate and potentially alter guidelines to reflect the most effective screening strategies for patients with AMH.

Written by: Zhamshid Okhunov, MD Department of Urology, University of California, Irvine


Read the Abstract


References:

1.Mohr DN, Offord KP, Melton LJ III. Isolated asymptomatic microhematuria: a cross-sectional analysis of test-positive and test-negative patients. J Gen Intern Med. 1987;2(5):318-324.

2. Loo RK, Lieberman SF, Slezak JM, et al. Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc. 2013;88(2):129-138. 

3. Mohr DN, Offord KP, Owen RA, Melton LJ III. Asymptomatic microhematuria and urologic disease: a population-based study.JAMA. 1986;256 (2):224-229. 

4. Carson CC III, Segura JW, Greene LF. Clinical importance of microhematuria.JAMA. 1979;241(2): 149-150. 

5. Golin AL, Howard RS. Asymptomatic microscopic hematuria.J Urol. 1980;124(3):389-391. 

6. Bard RH. The significance of asymptomatic microhematuria in women and its economic implications: a ten-year study. Arch Intern Med. 1988;148(12):2629-2632

7. Seklehner S, Remzi M, Fajkovic H, et al. Prospective multi-institutional study analyzing pain perception of flexible and rigid cystoscopy in men. Urology. 2015;85(4):737-741. 

8. Herr HW. The risk of urinary tract infection after flexible cystoscopy in patients with bladder tumor who did not receive prophylactic antibiotics.J Urol. 2015;193(2):548-551. 

9. Silver SA, Shah PM, Chertow GM, Harel S, Wald R, Harel Z. Risk prediction models for contrast induced nephropathy: systematic review. BMJ. 2015;351:h4395. 

10. Subramanian S, Tumlin J, Bapat B, Zyczynski T. Economic burden of contrast-induced nephropathy: implications for prevention strategies.J Med Econ. 2007;10(2):119-134. 

11. Morgan AE, Berland LL, Ananyev SS, Lockhart ME, Kolettis PN. Extraurinary incidental findings on CT for hematuria: the radiologist’s role and downstream cost analysis. AJR Am J Roentgenol. 2015;204(6):1160-1167. 

12. Heller MT, Tublin ME. In search of a consensus: evaluation of the patient with hematuria in an era of cost containment. AJR Am J Roentgenol. 2014;202 (6):1179-1186.