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Microscopic Hematuria and Transitions of Care: Are

Patients Appropriately Cared For?

MicroscopicHematuria&TransitionsofCare

Presenting Author: Ramy Sedhom, MD

PGY‐2 Resident, Rutgers Robert Wood Johnson 

Objectives:

• Recognize the transition from hospital to home as vulnerable period for adverse events

• Review ACP Clinical Guidelines and High-Value Care

• Demonstrate the lapses in transitions of care regarding workup of microscopic hematuria

Background

• High-risk patients with hematuria warrant an outpatient evaluation for bladder cancer

• The presence of microscopic hematuria may often be missed by primary care physicians after hospital discharge

• The story of Mr. Jones

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Background

• We investigated whether outpatient physicians routinely followed-up incidental microscopic hematuria on urinalysis performed during an inpatient visit for patients at high-risk for bladder carcinoma

Introduction

• Bladder cancer is the fourthmost common cancer in men and fifth most common cancer overall

• Most patients are diagnosed after presenting with hematuria

Introduction• American Urologic Association (AUA) best practice policy:

–High Risk Patients: smoking, exposures full urologic evaluation after 1 UA documenting at least 3 red blood cells per high powered field***

–Evaluation includes cystoscopy, cytology*, and upper tract imaging*

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Introduction

• There are few studies evaluating uptake of these recommendations by primary care physicians

ACP Advice for High Value Care

#1 – Ask about gross hematuria in ROS 

#2‐ UA is not for screening in asymptomatic adults 

#3 – Confirm heme + with microscopic analysis! 

#4‐ REFER to UROLOGY ALL gross hematuria! 

#5‐ Consider urology if no clear benign cause! *

#6 – Evaluate hematuria EVEN if on antiplatelet or anticoagulant therapy

#7 – DON’T GET URINE CYTOLOGY

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What evidence do we have?

• Two studies found suboptimal referral patterns for microscopic hematuria• A survey of 778 primary care physicians

found only 36% routinely referred high risk patients to urologists.

• Similarly, a health plan database of 926 patients with hematuria when queried, had lower referral rates of 26%.

What evidence do we have?

• Survey of primary care physicians from 2 US metropolitan areas reported that 64% of microscopic hematuria findings were not routinely referred for urologic evaluation• 36% did not routinely refer gross

hematuria!!!!

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What evidence do we have?

• SEER-Medicare database found delays >9 months from first claim of gross hematuria in the year prior to diagnosis of bladder cancer were more likely to die of the disease than those referred in 3 months or less (p<0.001).

RealityAdmitted for COPD Exacerbation

RealityAdmitted for COPD Exacerbation

Find microscopic hematuria                   

Outpatient work‐up

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RealityAdmitted for COPD Exacerbation

Find microscopic hematuria                   Outpatient work‐up

Patient is discharged

Patient is readmitted with pneumonia

Patient follows up with primary 

Alternate Reality

Clinic evaluation of a diabetic 

Order U/A to evaluate for proteinuria

Incidentally find microscopic hematuria

Old News• Medical information patients receive is poorly

retained:

• Recent study in JAMA: in patient discharge education only 60% of patients were able to accurately describe their diagnosis when asked

• Same study: only 44% of patients that had a follow-up visit scheduled with a PCP or cardiologist could accurately recall the details of either appointment

• Do we write it on the discharge summary?

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Study Design

• Retrospective chart review of inpatient/outpatient University Hospital based EMR• Transcripts, progress notes, imaging

results, referrals, laboratory results

Study Design

• Inclusion Criteria:• High Risk Patients:

• Age >50, >10-year smoking history, and/or >15 year environmental exposure

• Exclusion Criteria:• History of urologic malignancy, gross

hematuria, active urinary tract infection, or urolithiasis

Study Design

• Evaluated initial UA during admission.

• Audited subsequent outpatient charts for 1 year. Reviewed if had prior evaluation.

• Microscopic hematuria: defined as ≥ 3 RBC/HPF on sediment.

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Study Design

• Did the patient receive appropriate evaluation?

– Based on American Urologic Association (AUA) guidelines

•Urologic consultation for cystoscopy 

•Upper tract imaging for high‐risk patients with hematuria

Study Design

• Univariate/multivariate regression analysis performed to identify factors associated with further work‐up or referral to urology

– Variables included age, sex, tobacco use, number of pack years and environmental risks

Results• 154 patients meeting inclusion criteria

• 86 (55.6%) were seen by their PCP following hospital discharge. 

– 37 (43%) had no further evaluation.

• TESTING INCLUDED: 33% urinalysis, 11% urine culture, 12% cytology, and 26% imaging. 

• Only 14% received urologic referral for cystoscopy. 

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Results

–Of the subjects who had repeated urinalysis, 51% were still positive for hematuria.

Table 1. Evaluation of Subjects with Microscopic Hematuria

Evaluation Overall N=86

No. (%)

Nothing 37 (43%)

Repeat UA 28 (33%)

Urine Culture 9 (10%)

Cytology 10 (12%)

Imaging

All imaging 22 (26%)

CT 11 (13%)

US 7 (8%)

MRI 4 (5%)

Referral to Urology/Cystoscopy  12 (14%)

High Risk Patients w/Hematuria (154 patients)

No subsequent follow-up(68 patients)

Followed in University Clinic(86 patients)

No further evaluation(37 patients)

Had additional testing(49 patients)

Repeated UA(28 patients)

Urine Culture(9 patients)

Cytology(10 patients)

Imaging(22 patients)

CT (11 patients)

Cystoscopy(12 patients)

US (7 patients)

MRI(4 patients)

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Results– Only age was statistically significant with patients 

>75 having a decreased likelihood of evaluation. 

• Of the 49 patients who received further evaluation, 30 (61%) were smokers. 

• Similarly, of those who underwent cystoscopy, 24 (49%) were smokers. 

Results– On multivariate analysis, with a model including age, gender, occupational exposure, tobacco use, and smoking pack‐year history, absence of smoking history was associated with a 2.5 decreased likelihood of evaluation (odds ratio 2.45, 95% CI, 1.10‐7.24, p=<0.05) 

– Nearly 4‐fold increased risk of no cystoscopy (Odds ratio, 3.91; 95% CI, 1.16‐15.1, p=<0.05). 

Conclusion

Patients at high risk for bladder carcinoma who are found to have microscopic hematuria during an inpatient admission are rarely thoroughly evaluated when discharged from the hospital. 

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Conclusion• 25% of bladder cancers are diagnosed at an advanced stage

– Significantly lower survival than patients with non‐invasive disease

–Women present with more advanced disease, worse outcomes

Conclusion

•Areas of future studies:

–Evaluate reasons for lapses in transitions of care

–Test interventions to improve proper evaluation

•Education or structured, reflexive protocols

Acknowledgements• Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic 

microscopic hematuria in adults: the American Urological Association best practice policy‐ part I: definition, detection, prevalence, and etiology. Urology. 2001; 57: 599‐603

• Cohen RA, Brown RS. Clinical practice. Microscopic hematuria. NEJM. 2003; 348: 2330‐2338.

• Neider AM, Lotan Y, Nuss GR, et al. Are patients with hematuria appropriately referred to Urology? A multi‐institutional questionnare based survey. Urol Oncol. 2008 

• Horwitz, et al. Quality of Discharge Practices and Patient Understanding at an Academic Medical Center. JAMA Internal Medicine. 2013; 173(18):1715‐1722.

• Neilsen M, Qaseem A. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High‐Value Care from the American College of Physicians. Ann Intern Med, 2016. 

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Questions?