Do High-Risk Patients Diagnosed with Microscopic Hematuria by Primary Care Providers Undergo Urologic Consultation and Receive Guideline Concordant Care?
Clemens An, BS1, Jake Jeong, BS2, Evan Gaston, MD, JD, MA1, Amanda Kennedy, PhD1, Kevan Sternberg, MD3.
1The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, VT, USA, 2Cornell University, Ithaca, NY, USA, 3University of Massachusetts Memorial Department of Urology, Worcester, MA, USA.
BACKGROUND: Microscopic hematuria (MH) is a common diagnosis seen in the primary care setting. Guidelines exist to direct the urologic evaluation of MH however, primary care management, including need for specialist referral, is less well defined. Patients at high risk for urologic malignancy are particularly important to ensure appropriate diagnostic evaluations are performed. Our goal was to identify primary care patients with MH and describe the diagnostic evaluations they received. For high-risk patients, we also evaluated whether the work-ups performed were consistent with the 2020 AUA/SUFU guidelines. METHODS: A retrospective review of patients presenting to the primary care outpatient clinics at an academic medical center with a diagnosis of MH was performed from 1/1/2020 to 12/31/2021. Patient demographics, risk factors, diagnostic tests and visits with urology were recorded. Patients were classified as low, intermediate, and high-risk for urologic malignancy based on the 2020 AUA/SUFU guidelines. Descriptive statistics were generated to describe outcomes. RESULTS: 368 patients had a diagnosis of MH. The average age of the cohort was 62.5 years and 243 (66.0%) were female. 267/368 (72.6%) patients had all pertinent data available for risk stratification. 156 (58.4%) were considered high-risk (HR) with an average age of 63.4 years and 84 (53.8%) were female. Fifty-five (35.3%) high-risk patients had a urologic visit following the MH diagnosis; 33 out of 108 females (30.6%) and 22 out of 48 (45.8%) males were seen by urology. The average age of the patients seen by urology was 62.1 years and those not seen was 62.4 years. Twenty-nine (18.6%) of the high-risk patients presented with dysuria: 12 (41.4%) were seen by urology while 17 (58.6%) did not have a urology visit. Of the 55 HR patients seen by urology, 41 (75%) were evaluated with imaging studies and/or cystoscopy. Thirteen of the evaluations (31.7%) consisted of both CT urography and cystoscopy in-line with guideline recommendations. Twenty-eight (68.3%) of the work-ups were guideline discordant: 10 (24.4%) with CT urogram alone, 4 (9.8%) cystoscopy alone, and 14 (34.1%) with other imaging studies (ultrasound and/or CT other). Of the 14 who received other imaging studies, 5 (35.7%) received only ultrasound, 4 (28.6%) received only CT other, and 5 (35.7%) received both ultrasound and CT other. (Figure 1) CONCLUSIONS: A large portion of patients diagnosed with MH by primary care providers were considered high-risk based on the AUA/SUFU MH guidelines. Only 35% of these high-risk patients were seen by urology in our cohort. While most received some form of evaluation, only about 1/3 of these were guideline concordant. Female patients were seen less frequently by urology compared to male patients and a higher percentage of high-risk patients presenting with dysuria were not seen by urology. Future efforts should focus on ensuring appropriate urologic referral from primary care providers as well as ensuring that urologic management is guideline concordant in this high-risk population. 
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