Background: High-risk patients with hematuria often warrant an outpatient evaluation for bladder cancer; however the presence of microscopic hematuria may often be missed by primary care physicians after hospital discharge. Whether outpatient physician’s routinely follow-up incidental microscopic hematuria on urinalysis performed during inpatient visits is yet to be fully elucidated. Our aim was to assess physician trends in the work-up of microscopic hematuria in high-risk patients for bladder carcinoma seen in the clinic following hospital discharge.
Methods: We retrospectively reviewed a database of patients with microscopic hematuria on initial urinalysis during an inpatient admission from 2009 to 2012. Patients were identified as high risk based on age ≥50, ≥ 10-year smoking history, and/or ≥ 15 year environmental exposure. Excluded were patients with history of urologic malignancy, gross hematuria, active urinary tract infection, or urolithiasis. We evaluated the initial urinalysis of an inpatient admission and subsequent outpatient follow-up for one year. Microscopic hematuria was defined as ≥ 3 RBC/HPF. Chart review was performed to determine if this subset with microhematuria received appropriate evaluation. Appropriateness was based on American Urologic Association (AUA) guidelines recommending urologic consultation for cystoscopy or upper tract imaging for evaluation of high-risk patients with hematuria. Univariate and multivariate logic regression analysis was 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: Of the 401 patients available for analysis, microhematuria was detected in 154 participants (38.4%). Of the patients found to have microhematuria, 86 (55.6%) were seen by their primary following hospital discharge. 37 (43%) had no further evaluation. Of the remaining patients who had additional testing, 33% had urinalysis repeated, 11% a urine culture, 12% cytology, and 26% received imaging. Only 14% received urologic referral for cystoscopy. Of the subjects who had repeated urinalysis, 51% were still positive for hematuria. Univariate and multivariate analysis were performed to identify factors associated with further evaluation and/or referral for cystoscopy. Only age was statistically significant with 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. 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) and a nearly 4-fold increased risk of no cystoscopy (Odds ratio, 3.91; 95% CI, 1.16-15.1, p=<0.05).
Conclusions: Patients at high risk for bladder carcinoma based on traditional risk factors of age, ≥10 pack year smoking history, or environmental exposure who are found to have microscopic hematuria during an inpatient admission are rarely thoroughly evaluated when discharged from the hospital. Further studies are needed to evaluate both the reasons for lapses in transitions of care and the effectiveness of guidelines in the work-up for hematuria.