Evaluation Of Hematuria Research Articles

Detection of Alport gene variants in children and young people with persistent haematuria.

Genetic kidney disease is an important cause of persistent microscopic haematuria in children and young people. We aimed to determine the frequency of variants in the Alport syndrome genes (COL4A3, COL4A4 or COL4A5) in individuals under 18 years of age presenting with persistent microscopic haematuria to a single specialist centre in the UK over a 10-year period. We conducted a retrospective longitudinal study of individuals referred to a tertiary paediatric nephrology service with persistent microscopic haematuria between April 2012 to 2022. A total of 224 individuals (female 51.8%) were evaluated with persistent microscopic haematuria of greater than 6 months duration. The age at presentation was 7.5 ± 4.3 years (mean ± SD) with a duration of follow-up of 6.8 ± 4.6 years (mean ± SD). Targeted exome sequencing was performed in 134 individuals and 91 (68%) had a pathogenic or likely pathogenic variant in COL4A3, COL4A4 or COL4A5. Only 49.5% of individuals with identified variants had a family history of microscopic haematuria documented and 37.4% (34/91) had additional proteinuria at presentation. COL4A5 was the most common gene affected and missense variants affecting glycine residues were the most common variant type. Over two-thirds of children and young people who underwent genetic testing had an identifiable genetic basis for their microscopic haematuria and over half did not have a documented family history. Genetic testing should be part of the evaluation of persistent microscopic haematuria despite a negative family history.

Evaluation and Management of Hematuria in Children

Evaluation and Management of Hematuria in Children

Effect of Private Equity Ownership on Access to Outpatient Urologic Cancer Care in Medicare Recipients

To compare appointment availability and wait times between private equity-owned and non-private equity-owned urology clinics for 2 common urologic complaints. We identified all PE-owned urology clinic locations as of June 2022 (n=390). For each PE-owned location, a geographically matched, non-PE-owned clinic was identified. Each office was called using a "secret shopper" method with a standardized script, requesting an appointment on behalf of their Medicare-aged father for evaluation of gross hematuria or elevated prostate-specific antigen (PSA). The primary outcome was appointment availability, and the secondary outcome was wait time until soonest appointment. PE-owned and non-PE-owned clinics treated the presenting complaints with similar frequency (gross hematuria: 85% vs88%, P=.3, elevated PSA: 93% vs94%, P=.5). Wait time in days until the next available appointment was similar for PE-owned clinics compared to non-PE clinics for both complaints (gross hematuria: 16 vs13, P=.06, elevated PSA: 18 vs19, P=.7). If available, the time in days until the soonest next appointment with an advanced practice provider was also similar between PE-owned and non-PE clinics (gross hematuria: 13 vs11, P=.07, elevated PSA: 13 vs12, P=.6). Overall, there were no large-scale differences in access to outpatient urologic care between PE-owned clinics and non-PE-owned clinics. Access to care in PE-owned clinics is likely clinically similar to geographic-matched controls for Medicare patients with gross hematuria or elevated PSA.

A novel model of artificial intelligence based automated image analysis of CT urography to identify bladder cancer in patients investigated for macroscopic hematuria.

To evaluate whether artificial intelligence (AI) based automatic image analysis utilising convolutional neural networks (CNNs) can be used to evaluate computed tomography urography (CTU) for the presence of urinary bladder cancer (UBC) in patients with macroscopic hematuria. Our study included patients who had undergone evaluation for macroscopic hematuria. A CNN-based AI model was trained and validated on the CTUs included in the study on a dedicated research platform (Recomia.org). Sensitivity and specificity were calculated to assess the performance of the AI model. Cystoscopy findings were used as the reference method. The training cohort comprised a total of 530 patients. Following the optimisation process, we developed the last version of our AI model. Subsequently, we utilised the model in the validation cohort which included an additional 400 patients (including 239 patients with UBC). The AI model had a sensitivity of 0.83 (95% confidence intervals [CI], 0.76-0.89), specificity of 0.76 (95% CI 0.67-0.84), and a negative predictive value (NPV) of 0.97 (95% CI 0.95-0.98). The majority of tumours in the false negative group (n = 24) were solitary (67%) and smaller than 1 cm (50%), with the majority of patients having cTaG1-2 (71%). We developed and tested an AI model for automatic image analysis of CTUs to detect UBC in patients with macroscopic hematuria. This model showed promising results with a high detection rate and excessive NPV. Further developments could lead to a decreased need for invasive investigations and prioritising patients with serious tumours.

Utilization and Timing of Cystoscopy for Hematuria Evaluation by Advanced Practice Providers and Urologists

ObjectiveTo characterize differences between urologists and advanced practice providers (APPs) in utilization of cystoscopy for hematuria. MethodsWe identified patients initially evaluated for hematuria by a urologist or urology APP between 2015 and 2020 in the MarketScan® Research Databases. We determined whether they received a cystoscopy within six months of their urology visit and the number of days until cystoscopy. We used multivariable regression to analyze the association between these outcomes and whether the urology clinician was an advanced practice registered nurse (APRN), physician assistant (PA), or urologist. ResultsWe identified 34,470 patients with microscopic hematuria and 17,328 patients with gross hematuria. Patients evaluated by urologists more often received a same-day cystoscopy than those evaluated by APPs (13% vs 5.8%). The odds that patients evaluated for microscopic and gross hematuria received a cystoscopy were 46.2% and 26.2% lower, respectively, if they were evaluated by an APRN versus a urologist. Patients seeing an APRN for microscopic and gross hematuria also waited approximately 7 and 14 days longer for their cystoscopy, respectively. No differences were observed for patients evaluated by PAs versus urologists. ConclusionPatients evaluated for hematuria by an APRN were less likely to receive a cystoscopy and had a longer wait until the procedure compared to those evaluated by a urologist; however, no differences were observed between PAs and urologists. Better understanding APP integration into urology clinics is warranted.

First Report of Asymptomatic Solitary High-Grade B-Cell Lymphoma NOS: An Enigmatic Entity

Background High-grade B cell lymphoma (HGBL) is a new disease entity introduced by WHO in 2016, including two types: HGBL with a double hit (DH) or triple hit (TH) and HGBL, not otherwise specified (NOS). HGBL DH/TH are defined by genetic rearrangements of specific oncogenes MYC, BCL2 and/or BCL6, while HGBL NOS is defined purely base on morphology in the absence of these genes. HGBL DH/TH is known for its poor prognostication given its propensity to rapidly progress and disseminate, however HGBL NOS remains ill-defined and poorly understood with no tangible literature describing its clinical nature and therapeutic susceptibility. Case presentation A 76-year-old post-menopausal woman with no significant PMH presented for evaluation of painless hematuria during a routine office visit. Evaluation with imaging showed a suspicious incidental liver mass concerning for possible metastatic or primary liver cancer. Obtained labs were unremarkable, including serum LDH, serological testing for hepatitis B/C and HIV1/2, and typical tumor markers. PET scan showed focal uptake of tracer in liver with no nodal involvement. Liver biopsy revealed diffuse infiltration by atypical lymphocytes. Immunohistochemical analysis showed CD20 and CD10 positivity, negative CD30, and high Ki-67 proliferation rate of 100%, however the absence of MYC, BCL6, BCL2, and t(8;14) rearrangements on FISH ruled out Burkitt and DH/TH lymphoma, consistent with HGBL-NOS. Following discussions with Henry Ford Lymphoma Tumor Board, patient was treated with six cycles of R-CHOP, where follow-up imaging indicated remission of her lymphoma. Conclusion This represents an extraordinary first report of HGBL NOS manifesting as an isolated primary hepatic lymphoma in the complete absence of clinical symptoms. The significance of this case lies in its atypical extra-nodal site of involvement and total absence of clinical symptoms and serological markers, underscoring the unfulfilled need to further describe this enigmatic entity.

Discrepant guidelines in the evaluation of hematuria.

To assess discrepancies in current imaging recommendations for hematuria among North American societies: American College of Radiology (ACR), American Urological Association (AUA), and Canadian Urological Association (CUA). The latest available ACR Appropriateness Recommendations, AUA guidelines, and CUA guidelines were reviewed. AUA and CUA guidelines imaging recommendations by variants and level of appropriateness were converted to match the style of ACR. Imaging recommendations including modality, anatomy, and requirement for contrast were recorded. Clinical variants included microhematuria without risk factors, microhematuria with risk factors, gross hematuria, and microhematuria during pregnancy. CUA recommends ultrasound kidneys as the first-line imaging study in the first 3 variants; pregnancy is not explicitly addressed. For hematuria without risk factors, ACR does not routinely recommend imaging, while AUA recommends shared decision-making to decide repeat urinalysis versus cystoscopy with ultrasound kidneys. For hematuria with risk factors and gross hematuria, ACR recommends CT urography; MR urography can also be considered in gross hematuria. AUA further stratifies intermediate- and high-risk patients, for which ultrasound kidneys and CT urography are recommended, respectively. For pregnancy, ACR and AUA both recommend ultrasound kidneys, though AUA additionally recommends consideration of CT or MR urography after delivery. There is no universally agreed upon algorithm for diagnostic evaluation. Discrepancies centered on the role of upper tract imaging with ultrasound versus CT. Prospective studies and/or repeat simulation studies that apply newly updated guidelines are needed to further clarify the role of imaging, particularly for patients with microhematuria with no and intermediate risk factors.

Diagnostic yield of upper tract imaging performed for hematuria screening: Results from a national, privately-insured cohort

ObjectivesTo increase the population-level understanding of upper tract imaging evaluation during risk-based hematuria assessment. Using a national, privately-insured cohort, we evaluated the rates of imaging and the diagnostic yield of each imaging modality. We hypothesized that the rate of upper tract disease would be low and that the benefit of computed tomography over renal ultrasound would be limited. MethodsWe identified patients with an incident diagnosis of microscopic or gross hematuria between 2010 and 2015 within the MarketScan database. Multivariable logistic regression was used to predict the adjusted likelihood of any upper tract finding, with a subset analysis limited to malignant outcomes. ResultsWe identified 466,710 patients; 150,880 (32.3%) received ultrasound, 219,449 (47.0%) received computed tomography, and 96,381 (20.7%) received other imaging. Ultrasound detected 1,469 findings among 150,880 patients (1%); computed tomography detected 3,764 findings among 219,449 patients (1.7%); other imaging detected 2,612 findings among 96,381 patients (2.7%) (P < 0.0001). When adjusted for comorbidities, increased age, male sex, increased Elixhauser index, gross hematuria, and CT or other imaging were associated with upper tract findings, in the overall and subset analysis (all p < 0.0001). ConclusionsThe diagnostic yield of imaging is higher than expected; however, the detection rate remained low. As supported by updated clinical practice guidelines, clinicians should pursue risk-based imaging strategies during hematuria evaluation, although these data may support increased utilization of ultrasound at the initial evaluation.

Performance Characteristics of a Rule-Based Electronic Health Record Algorithm to Identify Patients with Gross and Microscopic Hematuria.

Two million patients per year are referred to urologists for hematuria, or blood in the urine. The American Urological Association recently adopted a risk-stratified hematuria evaluation guideline to limit multi-phase computed tomography to individuals at highest risk of occult malignancy. To understand population-level hematuria evaluations, we developed an algorithm to accurately identify hematuria cases from electronic health records (EHRs). We used International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, urine color, and urine microscopy values to identify hematuria cases and to differentiate between gross and microscopic hematuria. Using an iterative process, we refined the ICD-9 algorithm on a gold standard, chart-reviewed cohort of 3,094 hematuria cases, and the ICD-10 algorithm on a 300 patient cohort. We applied the algorithm to Geisinger patients ≥35 years (n = 539,516) and determined performance by conducting chart review (n = 500). After applying the hematuria algorithm, we identified 51,500 hematuria cases and 488,016 clean controls. Of the hematuria cases, 11,435 were categorized as gross, 26,658 as microscopic, 12,562 as indeterminate, and 845 were uncategorized. The positive predictive value (PPV) of identifying hematuria cases using the algorithm was 100% and the negative predictive value (NPV) was 99%. The gross hematuria algorithm had a PPV of 100% and NPV of 99%. The microscopic hematuria algorithm had lower PPV of 78% and NPV of 100%. We developed an algorithm utilizing diagnosis codes and urine laboratory values to accurately identify hematuria and categorize as gross or microscopic in EHRs. Applying the algorithm will help researchers to understand patterns of care for this common condition.

Toward the Deimplementation of Computed Tomography Urogram for Patients With Low- to Intermediate-risk Microscopic Hematuria: A Mixed-method Study of Factors Influencing Continued Use.

Citing high costs, limited diagnostic benefit, and ionizing radiation-associated risk from CT urogram, in 2020 the AUA revised its guidelines from recommending CT urogram for all patients with microscopic hematuria to a deintensified risk-stratified approach, including the deimplementation of low-value CT urogram (ie, not recommending CT urogram for patients with low- to intermediate-risk microscopic hematuria). Adherence to revised guidelines and reasons for continued low-value CT urogram are unknown. With the overarching objective of improving guideline implementation, we used a mixed-method convergent explanatory design with electronic health record data for a retrospective cohort at a single academic tertiary medical center in the southeastern United States and semistructured interviews with urology and nonurology providers to describe determinants of low-value CT urogram following guideline revision. Of 391 patients with microscopic hematuria, 198 (51%) had a low-value CT urogram (136 [69%] pre-guideline revision, 62 [31%] postrevision). The odds of ordering a low-value CT urogram were lower after guideline revisions, but the change was not statistically significant (OR: 0.44, P = .08); odds were 1.89 higher (P = .06) among nonurology providers than urology providers, but the difference was not statistically significant. Provider interviews suggested low-value CT urogram related to nonurology providers' limited awareness of revised guidelines, the role of clinical judgment in microscopic hematuria evaluation, and professional and patient influences. Our findings suggest low-value CT urogram deimplementation may be improved with guidelines and implementation support directed at both urology and nonurology providers and algorithms to support guideline-concordant microscopic hematuria evaluation approaches. Future studies should test these strategies.

CarePoint assay in the management of bladder cancer: A pilot study.

e16593 Background: Bladder cancer afflicts over 700,000 patients in the US and is one of the most expensive cancers to treat. Given a recurrence rate of up to 70%, regular often prolonged surveillance is required. In addition to urine based tests, current standard evaluation includes cystoscopy which is burdensome for patients and physicians; there has long been a need for a reliable non-invasive alternative diagnostic tool. While there is a wealth of literature on urinary biomarkers, no single biomarker has demonstrated consistent high sensitivity and specificity. Methods: The CarePoint Assay, a point-of-care (POC) tool, can perform multiple biomarker tests simultaneously. In this study, urine was collected from patients undergoing urologic evaluation for hematuria from three separate institutions. The urine was sent for central evaluation and the CarePoint Assay was used to detect the bladder cancer biomarker BTA. POC results were then compared to results from a highly sensitive 6-hour ELISA. The accuracy of distinguishing high-grade tumors, low-grade tumors and no tumor present were compared between the two methods. Results: The CarePoint Assay demonstrated excellent correlation with the ELISA in detecting biomarker levels and distinguishing high-grade tumors as well as a superior specificity (88% versus 77%) for ELISA, sensitivity (52% vs. 72%) for ELISA and a limit of detection of 2.55 ng/mL (16 picomolar). Conclusions: With this high performance, the CarePoint Assay has the ability to detect and multiplex multiple other bladder cancer biomarkers with higher sensitivity and specificity. Additional biomarker analysis using the CarePoint Assay may yield the medically desired higher levels of sensitivity and specificity for a non-invasive point-of-care bladder cancer test, ultimately limiting the patient burden of bladder cancer surveillance.

Outcomes of Hematuria Evaluation by Advanced Practice Providers and Urologists

To examine the quality and costs of care for patients evaluated for hematuria by urologic advanced practice providers (APPs) and urologists. The roles of APPsin urology are growing, but their clinical and financial outcomes compared to urologists are not well understood. We conducted a retrospective cohort study of commercially insured patients using data from 2014 to 2020. We included adult beneficiaries with a diagnosis code for hematuria and an initial outpatient evaluation and management visit with a urologic APP or urologist. We assessed receipt of cystoscopy procedure, imaging study, bladder biopsy procedure, and bladder cancer diagnosis within 6 months of the initial visit. Secondary outcomes included the time until each of these outcomes occurred and the out-of-pocket spending and total payments. We identified 59,923 patients who were initially evaluated for hematuria. Visits with urologic nurse practitioners rather than urologists were associated with significantly lower odds of receiving cystoscopy procedures (odds ratio [OR] 0.93, 95% confidence interval [95% CI] 0.54-0.72, P < .001), imaging studies (OR 0.79, 95% CI 0.69-0.91, P < .001), and bladder biopsy procedures (OR 0.61, 95% CI 0.41-0.92, P = .02). Visits with urologic physician assistants were associated with 11% greater out-of-pocket payments (incident risk ratio1.11, CI 1.01-1.22, P = .02) and 14% greater total payments (incident risk ratio 1.14, CI 1.04-1.25, P = .004). There are clinical and financial differences in hematuria care delivered by urologic APPs and urologists. The incorporation of APPs into urologic care warrants further study, and specialty-specific training for APPs should be considered.

EConsult Provides a Novel Opportunity to Evaluate Hematuria Referrals for Medicaid Patients in the "Real-World" Community.

We utilized an eConsult program to assess the appropriateness and completeness of hematuria evaluation among one of the largest Medicaid networks in California, the Inland Empire Health Plan. We retrospectively reviewed all hematuria consults from May 2018 to August 2020. Patient demographic and clinical data were extracted from the electronic health record and dialogues between primary care provider and specialist including laboratory results and imaging. We calculated the proportions of imaging types and the outcome of the eConsults among patients. χ2 and Fisher's exact tests were used for statistical analysis. A total of 106 hematuria eConsults were submitted. Primary care provider evaluation for risk factors rates were low: 37% gross hematuria, 29% voiding symptoms/dysuria, 49% other urothelial risk factors or benign etiology, and 63% smoking. Only 50% of all referrals were deemed appropriate based on a history of gross hematuria or ≥3 red blood cells/high-power field on urinalysis without evidence of infection or contamination. Thirty-one percent of patients received a renal ultrasound, 2.8% received CT urography, 5.7% received other cross-sectional imaging, and 64% received no imaging. By the conclusion of the eConsult only 54% of patients were referred for a face-to-face visit. The use of eConsults allows for urological access in the safety-net population and presents a means to assess the urological needs in the community. Our findings suggest eConsults represent an opportunity to reduce the morbidity and mortality associated with hematuria among safety-net patients who are otherwise less likely to receive a proper evaluation.

Evaluation of Recurrent Gross Hematuria in a Patient With Metastatic Prostate and Concomitant Metastatic Kidney Cancer

Evaluation of Recurrent Gross Hematuria in a Patient With Metastatic Prostate and Concomitant Metastatic Kidney Cancer

MP09-13 COST OF UPPER TRACT IMAGING OBTAINED DURING HEMATURIA EVALUATION: ANALYSIS OF A NATIONAL CLAIMS DATABASE

You have accessJournal of UrologyCME1 Apr 2023MP09-13 COST OF UPPER TRACT IMAGING OBTAINED DURING HEMATURIA EVALUATION: ANALYSIS OF A NATIONAL CLAIMS DATABASE Alex Hannemann, Simon Kim, Boris Gershman, Michael Bronsert, Kayvon Kiani, Justin Achua, Rodrigo Rodrigues Pessoa, and Eric Ballon-Landa Alex HannemannAlex Hannemann More articles by this author , Simon KimSimon Kim More articles by this author , Boris GershmanBoris Gershman More articles by this author , Michael BronsertMichael Bronsert More articles by this author , Kayvon KianiKayvon Kiani More articles by this author , Justin AchuaJustin Achua More articles by this author , Rodrigo Rodrigues PessoaRodrigo Rodrigues Pessoa More articles by this author , and Eric Ballon-LandaEric Ballon-Landa More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003224.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The urologic workup following hematuria diagnosis burdens the healthcare system with significant cost. Using a privately-insured, claims-based national cohort, we sought to evaluate the cost of hematuria evaluation. We hypothesized that evaluation with contrast-enhanced computed tomography (CT) confers more cost to hematuria evaluation than renal ultrasound (US). METHODS: Using a national, privately insured database (MarketScan), we identified all individuals with an incident diagnosis of hematuria. We included patients who underwent cystoscopy and upper tract imaging within 3 months of diagnosis. We tabulated the costs of the imaging study as well as the total healthcare cost per patient. A multivariable model was developed to evaluate patient risk factors associated with total healthcare costs. RESULTS: We identified 377,359 patients with hematuria who underwent evaluation. Median costs associated with upper tract imaging were $425 overall, $359 for CT with contrast, $117 for US, $622 for MRI, and $226-253 for other imaging (CT without contrast, retrograde pyelogram). Median cystoscopy cost was $294. Total healthcare costs per patient were highest amongst patients undergoing MRI and CT imaging. When adjusted for comorbidities, tobacco use, higher Elixhauser index, gross hematuria and male sex were associated with higher costs of hematuria evaluation. Based upon previously presented rates of upper tract findings, we found a total cost per upper tract lesion to be $19,300 for US, $34,352 for CT, and $25,000 overall. Annual spending on imaging was 4- to 5-fold spending on cystoscopy (Figure 1). CONCLUSIONS: Hematuria evaluation confers a significant cost burden to the healthcare system, primarily driven by upper tract imaging. Patients with hematuria risk factors were associated with higher total healthcare costs of screening. Increased adoption of US-based imaging strategies may lead to higher value care. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e110 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alex Hannemann More articles by this author Simon Kim More articles by this author Boris Gershman More articles by this author Michael Bronsert More articles by this author Kayvon Kiani More articles by this author Justin Achua More articles by this author Rodrigo Rodrigues Pessoa More articles by this author Eric Ballon-Landa More articles by this author Expand All Advertisement PDF downloadLoading ...

MP49-12 ADVANCING COMPREHENSIVE URO-ONCOLOGIC CARE FOR THE URBAN UNDERSERVED

You have accessJournal of UrologyCME1 Apr 2023MP49-12 ADVANCING COMPREHENSIVE URO-ONCOLOGIC CARE FOR THE URBAN UNDERSERVED Kit Yuen, Alexis Steinmetz, Mark Ninomiya, and Divya Ajay Kit YuenKit Yuen More articles by this author , Alexis SteinmetzAlexis Steinmetz More articles by this author , Mark NinomiyaMark Ninomiya More articles by this author , and Divya AjayDivya Ajay More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003297.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Racial and socioeconomic disparities in the incidence, treatment, and outcomes of urologic cancers are well documented; solutions to these inequities are not. The purpose of this study was to assess the feasibility and effectiveness of integrating a urologic specialty care clinic into an existing primary care infrastructure. We also aimed to increase trainees’ awareness of health inequities in urologic cancer care. METHODS: St. Joseph’s Neighborhood Center (SJNC) is a Catholic charity organization that provides health care and social services to individuals without health insurance. University of Rochester Medical Center (URMC) has a long-standing partnership with SJNC through a student-led primary care clinic. In February 2021, URMC residents organized bi-monthly urology clinics at SJNC staffed by attending, resident, and student volunteers. A preliminary analysis of clinic records was conducted. Qualitative data was obtained through direct observation of program processes and informal feedback with volunteers. RESULTS: Twelve clinics have been held. Four to 6 patients referred by SJNC’s primary care team were seen in each 2-hour evening clinic. Patients were evaluated by student/resident teams, followed by discussion with an attending urologist. Approximately 40% of patients were referred for suspected genitourinary malignancy. Multiple barriers to oncologic diagnostics were identified (Table 1). Hematuria evaluations were the most difficult to coordinate due to cost and logistics of imaging and procedures. Trainees reported an increased awareness of cancer care disparities and the practical challenges of overcoming access to specialty care in a medically underserved community. CONCLUSIONS: Comprehensive cancer care is routinely fragmented or unavailable to medically underserved populations. Despite a nationally recognized cancer center in Rochester, NY, many individuals living within the urban area struggle to obtain routine cancer screening and evaluations for potentially treatable or curable cancers. We outlined a feasible model of integrating access to uro-oncologic care into a primary care system with sustainable buy-in from local partners. Future directions are to increase the frequency of clinics, access to clinical trials, and decreasing the financial burdens of care. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e683 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kit Yuen More articles by this author Alexis Steinmetz More articles by this author Mark Ninomiya More articles by this author Divya Ajay More articles by this author Expand All Advertisement PDF downloadLoading ...

MP39-02 OUTCOMES OF HEMATURIA EVALUATION BY ADVANCED PRACTICE PROVIDERS AND UROLOGISTS

You have accessJournal of UrologyCME1 Apr 2023MP39-02 OUTCOMES OF HEMATURIA EVALUATION BY ADVANCED PRACTICE PROVIDERS AND UROLOGISTS Max J Hyman, Ted Skolarus, Kim Litwack, David Meltzer, and Parth Modi Max J HymanMax J Hyman More articles by this author , Ted SkolarusTed Skolarus More articles by this author , Kim LitwackKim Litwack More articles by this author , David MeltzerDavid Meltzer More articles by this author , and Parth ModiParth Modi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The roles of advanced practice providers (APPs) in surgical practices are growing, but their clinical and financial outcomes are not well understood. We aimed to determine the quality and costs of care to patients initially evaluated for hematuria by urologic APPs rather than urologists. We hypothesized that patients initially evaluated by urologic APPs would receive fewer cystoscopy procedures and imaging studies, have longer waits until cystoscopy and imaging, and have higher out-of-pocket spending and total payments. METHODS: We performed a retrospective cohort study of administrative claims data from 2014-2020. We identified adults with hematuria and an initial outpatient visit with a urologic APP or urologist. We examined receipt of cystoscopy procedure, imaging study, bladder biopsy procedure, and bladder cancer diagnosis within six months of the initial visit. We also evaluated the time until each of these outcomes occurred, and the out-of-pocket (OOP) spending and total payments at three- and six-months after the initial visit. We used multiple logistic and negative binomial regression models, adjusted for beneficiary age, sex, baseline expenditures and comorbidities, location, and insurance details. RESULTS: We identified 59,923 patients (mean age 56.1 years; 51.7% female) who were initially evaluated for hematuria. Visits with urologic nurse practitioners rather than urologists were associated with significantly lower odds of receiving cystoscopy procedures (odds ratio (OR) 0.93, 95% confidence interval (95% CI) 0.54-0.72, p<0.001), imaging studies (OR 0.79, 95% CI 0.69-0.91, p<0.001), and bladder biopsy procedures (OR 0.61, 95% CI 0.41-0.92, p=0.02). Initial visits with urologic physician assistants were associated with 11% greater OOP payments (incident risk ratio (IRR) 1.11, CI 1.01-1.22, p=0.02) and 14% greater total payments (IRR 1.14, CI 1.04-1.25, p=0.004). Initial visits with any urologic APP were associated with longer waits until cystoscopy. There was no difference in the bladder cancer diagnosis rates by provider type. CONCLUSIONS: There are clinical and financial differences in hematuria care delivered by urologic APPs and urologists. The incorporation of APPs into urologic care warrants further study and specialty-specific training for APPs should be considered.Figure 1 Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e534 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Max J Hyman More articles by this author Ted Skolarus More articles by this author Kim Litwack More articles by this author David Meltzer More articles by this author Parth Modi More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluating posttransurethral resection of prostate hematuria severity using two methods: A cross-sectional study

Abstract Background Following transurethral resection of the prostate, postprocedure macroscopic hematuria must be evaluated. We developed a five-color table hematuria grading scale with visualized color references for health care workers to evaluate postprocedure hematuria severity and compared it with assessments made using the text hematuria grading scale. Methods Thirty hematuria samples from patients who had undergone transurethral resection of the prostate were evaluated twice by 17 doctors and 13 nurses. The main outcome was the postprocedure macroscopic hematuria severity, measured using the means obtained from the two hematuria grading methods (Meantext and Meanfive-color). Furthermore, we investigated the association between demographic factors including occupation, training years, and whether a urologist was involved in hematuria evaluation. Results The Meantext for 30 patients was 2.2489 ± 1.96*0.76862, whereas the Meanfive-color was 2.4222 ± 1.96*0.91268. The paired t test revealed a significant difference between Meantext and Meanfive-color (P = 0.00), meaning that the severity observed by medical staff was significantly milder using the text compared with the five-color hematuria grading scale. The Wilcoxon signed rank test between the variances of the two hematuria grading scales showed a Z score of −1.127 and p value of 0.026 without significant difference. Conclusions Our findings reveal that hematuria grading is method-dependent. Hematuria severity in patients who had undergone transurethral resection of the prostate with macroscopic hematuria assessed using a hematuria grading scale without visualized color references may be underestimated in clinical practice. With visualized color references, consistent counts did not negatively correlate to fewer years of experience in the surgery department.

The efficacy of ultrasonography for the detection of upper tract urothelial carcinoma

Ultrasonography and computed tomography urography are two commonly used modalities to image the upper tracts for the evaluation of hematuria. This study evaluated the efficacy of ultrasonography for the detection of upper tract urothelial carcinoma compared to computed tomography urography as a standard reference. This retrospective study included patients with urothelial carcinoma of the renal pelvis and/or ureter who were diagnosed using computed tomography urography and underwent surgical treatment. We calculated the sensitivity of ultrasonography in upper tract urothelial carcinoma diagnosis, further classified the degree of hydronephrosis on ultrasonography, and analyzed the relationship between the sensitivity and the degree of hydronephrosis and tumor location. Additionally, the usefulness of the combination of the screening ultrasonography findings, the presence of gross hematuria, and/or urine cytology was analyzed. This study included 136 patients with upper urothelial carcinoma. Ultrasonography in the diagnosis had 45.6% sensitivity, and ultrasonography findings, including the detection of hydronephrosis, were present in 72.8%. The presence of hydronephrosis and tumor location were associated with detection by ultrasonography. The tumor was identified in a total of 134 (98.5%) patients by combining tumor detection and hydronephrosis using ultrasonography with gross hematuria and positive urine cytology as screening. Ultrasonography showed acceptable sensitivity for upper tract urothelial carcinoma diagnosis. Considering the hydronephrosis findings, ultrasonography is a useful screening tool for upper tract urothelial carcinoma. Additionally, excessive computed tomography examinations can be reduced by adding gross hematuria and positive urine cytology.

Association of Rural Hospital for-Profit Status With Higher Publicly Reported Prices for the Components of Inpatient Hematuria Evaluation Among Commercially Insured Patients.

Rural patients have limited access to urological care and are vulnerable to high local prices. Little is known about price variation for urological conditions. We aimed to compare reported commercial prices for the components of inpatient hematuria evaluation between for-profit vs not-for-profit and rural vs metropolitan hospitals. We abstracted commercial prices for the components of intermediate- and high-risk hematuria evaluation from a price transparency data set. We compared hospital characteristics between those that do and do not report prices for a hematuria evaluation using the Centers for Medicare and Medicaid Services Healthcare Cost Reporting Information System. Generalized linear modelling evaluated the association between hospital ownership and rural/metropolitan status with prices of intermediate- and high-risk evaluations. Of all hospitals, 17% of for-profits and 22% of not-for-profits report prices for hematuria evaluation. For intermediate-risk, median price at rural for-profit hospitals was $6,393 (interquartile range [IQR] $2,357-$9,295) compared to $1,482 (IQR $906-$2,348) at rural not-for-profits and $2,645 (IQR $1,491-$4,863) at metropolitan for-profits. For high-risk, rural for-profit hospitals' median price was $11,151 (IQR $5,826-$14,366) vs $3,431 (IQR $2,474-$5,156) at rural not-for-profits and $4,188 (IQR $1,973-$8,663) at metropolitan for-profits. Rural for-profit status was associated with an additional higher price for intermediate- (relative cost ratio 1.62, 95% CI 1.16-2.28, P = .005) and high-risk evaluations (relative cost ratio 1.50, 95% CI 1.15-1.97, P = .003). Rural for-profit hospitals report high prices for components of inpatient hematuria evaluation. Patients should be aware of prices at these facilities. These differences may dissuade patients from undergoing evaluation and lead to disparities.