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Hematuria Referrals at a Safety Net Hospital: A Focus on Patient Demographics and Compliance
Liz B. Wang, MD¹, Remington T. Lim, BA², Christopher F. Noyes, BS², Batsheva R. Rubin, MPH², David S. Wang, MD¹, Shaun E. Wason, MD¹.
¹Boston University Medical Center, Boston, MA, USA, ²Boston University School of Medicine, Boston, MA, USA.

BackgroundHematuria accounts for over 20% of referrals to urology but prior studies show low completion rates of only 5-18%. Our study characterizes the referral trends for hematuria and analyzes the socioeconomic factors affecting follow-up appointment rates in a safety net hospital setting.
MethodsWe performed a retrospective review of patients referred to urology at an urban safety net hospital for microscopic and gross hematuria from 2018-2019. Analyzed variables included age, gender, race, primary spoken language, insurance type, BMI, medical comorbidities, and smoking history. Appropriateness of the referral and completion of the workup, including upper tract imaging and cystoscopy, were evaluated. Univariate analysis was performed using chi-square test, Fisher’s exact test or t-test, and odds ratios were calculated.
ResultsA total of 333 patients were referred for microscopic or gross hematuria. We excluded 45(13.5%) patients who did not show for consultation and 53(15.9%) patients with a known history of genitourinary malignancy or urolithiasis. Of the remaining 235 patients, 59.2% patients had a pre-referral urinalysis with microscopy and 28.9% had a urine culture. 5.5% patients had only a dipstick urinalysis and 16.2% had no urine studies. The majority of patients were non-White (68.5%) and publicly insured (75.3%). 40.8% were non-English speaking.
One hundred and fifty (63.8%) patients completed a full hematuria workup with both upper tract imaging and cystoscopy. Of the remaining 85 patients, 28 (11.9%) missed cystoscopy, 26 (11.1%) missed imaging, and 31 (13.2%) missed both. Those with erectile dysfunction (ED) had 77% decreased odds of completing the workup (p=0.016). Patients under 40 had 2.5x odds of not completing the hematuria workup (p=0.004). Of those referred for gross hematuria, patients with a history of recurrent urinary tract infections (UTI’s) had 87% decreased odds of completing the workup (p=0.007). Of those referred for microscopic hematuria, patients under 40 had 5.0x odds of not completing the workup (p=0.001). Odds of completing a hematuria evaluation, both microscopic and gross, was not significantly associated with other factors, including gender, BMI, smoking status, race, language, or insurance status.
ConclusionsWithin an urban safety net hospital system, 40% of hematuria referrals were missing the recommended urinalysis with microscopy. Although workup completion rates were higher compared to prior studies, they remain relatively low regardless of socioeconomic factors. Improving counseling for younger patients may improve hematuria completion rates. Simplified 2020 AUA hematuria guidelines, which obviate the need for cross sectional imaging, may also improve completion rates in future studies.
Table 1: Demographics of All Hematuria Referrals

		Total N (%) or mean ± SD
Age		55.4 ± 17.2
Gender	Female	95 (40.5)
	Male	150 (59.6)
Race	Black	92 (39.2)
	White	49 (20.9)
	Hispanic	56 (23.8)
	Asian	13 (5.5)
	Other	25 (10.6)
BMI		27.7 ± 5.8
Language	English	139 (59.2)
	Spanish	48 (20.4)
	Haitian-Creole	15 (6.4)
	Other	33 (14.0)
Smoking Status	Current	27 (11.5)
	Past	53 (22.6)
	Never	116 (49.4)
Insurance	Public	177 (75.3)
	Private	58 (24.7)
Comorbidities	Diabetes	35 (14.9)
	Hypertension	99 (42.1)
	Renal Disease	27 (11.5)
	BPH	31 (13.2)
	ED	13 (5.5)
	Recurrent UTI’s	19 (8.1)
	Indwelling catheter	9 (3.8)

Table 2: Patient Age and Completion of All Hematuria Workup

Age (years)	Workup Complete	Not Complete	% Complete	p-value
< 40	22	26	45.8	0.004
40-55	41	17	70.7
55-70	53	24	68.8
70+	34	18	65.5

Graph 1: Breakdown of Hematuria Workup Completion

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