Friedlander David F, Resnick Matthew J, You Chaochen, Bassett Jeffrey, Yarlagadda Vidhush, Penson David F, Barocas Daniel A
Vanderbilt University School of Medicine, Nashville, Tenn.
Department of Urologic Surgery, Vanderbilt University, Nashville, Tenn; Vanderbilt University, Center for Surgical Quality and Outcomes Research, Nashville, Tenn; Geriatric Research, Education, and Clinical Center, Tennessee Valley Veterans Administration Health Care System, Nashville, Tenn.
Am J Med. 2014 Jul;127(7):633-640.e11. doi: 10.1016/j.amjmed.2014.01.010. Epub 2014 Jan 28.
Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients aged more than 35 years. Nonetheless, less than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and nonclinical factors associated with evaluation of persons with newly diagnosed hematuria.
We performed a retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for nonclinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy or abdomino-pelvic imaging within 180 days after hematuria diagnosis. We modeled the association between clinical and nonclinical factors and appropriate hematuria evaluation.
We identified 2455 primary care patients aged 40 years or more and diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis; 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender, and anticoagulant use (P < .001, P = .036, P = .028, respectively). Addition of practice site improved the predictive discrimination of each model (P < .001). Evaluation was associated with a higher rates of genitourinary neoplasia diagnosis.
Patients with hematuria rarely underwent complete evaluation. Although established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions.
血尿是一种常见的临床症状，也是膀胱癌最常见的首发体征。美国泌尿外科学会建议对35岁以上的患者进行膀胱镜检查和腹盆腔成像检查。然而，出现血尿症状的患者中，接受适当评估的不到一半。我们试图确定与新诊断血尿患者评估相关的临床和非临床因素。
我们利用索赔数据和实验室值进行了一项回顾性队列研究。主要暴露因素是医疗机构，作为非临床、潜在可改变的变异来源的替代指标。主要结局是血尿诊断后180天内进行膀胱镜检查或腹盆腔成像检查。我们对临床和非临床因素与适当血尿评估之间的关联进行了建模。
我们确定了2455例40岁及以上的初级保健患者，他们在2004年至2012年期间被诊断为血尿，且无其他解释性诊断；13.7%的患者在180天内接受了膀胱镜检查。多因素逻辑回归显示，接受评估和未接受评估的患者在年龄、性别和抗凝剂使用方面存在显著差异（分别为P <.001、P =.036、P =.028）。加入医疗机构这一因素后，每个模型的预测辨别力都有所提高（P <.001）。评估与泌尿生殖系统肿瘤诊断率较高相关。
血尿患者很少接受全面评估。虽然已确定的恶性肿瘤风险因素与诊断性检查使用的增加有关，但与风险无关的因素，如医疗机构，也导致了显著差异。医疗机构之间的不一致是不可取的，可能需要进行质量改进干预。
