UNC-led study comparing tradeoffs of benefit, harm, and cost in hematuria evaluation published in JAMA Internal Medicine

UNC researchers led by Matthew Nielsen, MD, found that the risk stratification may optimize the balance of benefit, harm, and cost associated with diagnostic testing for a common condition called hematuria.

UNC-led study comparing tradeoffs of benefit, harm, and cost in hematuria evaluation published in JAMA Internal Medicine click to enlarge Dr. Matthew Nielsen was corresponding author for the study

Hematuria, or blood in the urine, is commonly encountered in clinical practice, with over 2 million American patients referred to urologists annually.  The association of this finding with occult urinary tract cancer led to the development of several guidelines, with differing recommendations for evaluation.  A study led by investigators at UNC published in this week’s print edition of JAMA Internal Medicine explores the tradeoffs of these different approaches.  Matthew Nielsen, Associate Professor of Urology and Adjunct Associate Professor of Epidemiology and Health Policy & Management, was the corresponding author for the study.  Other UNC-affiliated investigators include Mihaela Georgieva, Stephanie Wheeler, and Daniel Erim, from the Department of Health Policy and Management, and Mathew Raynor from the Department of Urology.

The authors synthesized information from the published literature to create a computer-based microsimulation model of 100,000 patients presenting with hematuria.  This study design permitted estimation of urinary cancer detection rates, costs, and harms, in particular the risk of radiation-induced future cancer associated with exposure to CT imaging, across the recommendations from five current guidelines. 

The most intensive recommendation, recommending CT and cystoscopy for all patients, was associated with marginally higher cancer detection rates, though this cost twice as much per patient evaluated and was associated with an estimated risk of radiation-induced future cancer in more than one out of 200 patients evaluated, more than 10 times higher than the additional number of cancers detected.  The authors conclude, “The balance of harms, advantages, and costs of hematuria evaluation may be optimized by risk stratification and more selective application of diagnostic testing in general and computed tomography imaging in particular.”

An accompanying editorial notes that “this study sets a good example for future guidelines development,” involving CT imaging, to the extent that the “morbidity and mortality associated with these radiation-induced cancers cannot be ignored.”  More information about the study can be found on a New England Journal of Medicine Journal Watch podcast interview with Dr. Nielsen.

Filed under: