Halpern Joshua A, Chughtai Bilal, Ghomrawi Hassan
Department of Urology, Weill Cornell Medicine, New York, New York.
Departments of Surgery and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
JAMA Intern Med. 2017 Jun 1;177(6):800-807. doi: 10.1001/jamainternmed.2017.0739.
Asymptomatic microscopic hematuria (AMH) is highly prevalent and may signal occult genitourinary (GU) malignant abnormality. Common diagnostic approaches differ in their costs and effectiveness in detecting cancer. Given the low prevalence of GU malignant abnormality among patients with AMH, it is important to quantify the cost implications of detecting cancer for each approach.
To estimate the effectiveness, costs, and incremental cost per cancer detected (ICCD) for 4 common diagnostic approaches evaluating AMH.
DESIGN, SETTING, AND PARTICIPANTS: A decision-analytic model-based cost-effectiveness analysis using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included adult patients with AMH on routine urinalysis with subgroups of high-risk patients (males, smokers, age ≥50 years) seen in the primary care or urologic referral setting.
Four diagnostic approaches were evaluated relative to the reference case of no evaluation: (1) computed tomography (CT) alone; (2) cystoscopy alone; (3) CT and cystoscopy combined; and (4) renal ultrasound and cystoscopy combined.
At termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH.
Of the 4 diagnostic approaches analyzed, CT alone was dominated by all other strategies, detecting 221 cancers at a cost of $9 300 000. Ultrasound and cystoscopy detected 245 cancers and was most cost-effective with an ICCD of $53 810. Replacing ultrasound with CT detected just 1 additional cancer at an ICCD of $6 480 484. Ultrasound and cystoscopy remained the most cost-effective approach in subgroup analysis. The model was not sensitive to any inputs within the proposed ranges. Using probabilistic sensitivity analysis, ultrasound and cystoscopy was the dominant strategy in 100% of simulations.
The combination of renal ultrasound and cystoscopy is the most cost-effective among 4 diagnostic approaches for the initial evaluation of AMH. The use of ultrasound in lieu of CT as the first-line diagnostic strategy will optimize cancer detection and reduce costs associated with evaluation of AMH. Given our findings, we need to critically evaluate the appropriateness of our current clinical practices, and potentially alter our guidelines to reflect the most effective screening strategies for patients with AMH.
无症状性镜下血尿（AMH）非常普遍，可能预示着隐匿性泌尿生殖系统（GU）恶性异常。常见的诊断方法在检测癌症的成本和有效性方面存在差异。鉴于AMH患者中GU恶性异常的患病率较低，量化每种方法检测癌症的成本影响非常重要。
评估评估AMH的4种常见诊断方法的有效性、成本以及每检测出一例癌症的增量成本（ICCD）。
设计、设置和参与者：基于决策分析模型的成本效益分析，使用医学文献中的数据。通过PubMed检索来确定所有关键模型输入的相关文献，每个输入均来自数据最可靠且适用性最强的临床研究。分析纳入了在初级保健或泌尿外科转诊机构中通过常规尿液分析发现有AMH的成年患者，以及高危患者亚组（男性、吸烟者、年龄≥50岁）。
相对于不进行评估的参考病例，评估了4种诊断方法：（1）单独使用计算机断层扫描（CT）；（2）单独使用膀胱镜检查；（3）CT与膀胱镜检查联合使用；（4）肾脏超声与膀胱镜检查联合使用。
在诊断期结束时，每10000名接受AMH评估的患者中检测出的癌症数量、成本（支付方视角）以及ICCD。
在所分析的4种诊断方法中，单独使用CT被所有其他策略所主导，检测出221例癌症，成本为930万美元。超声和膀胱镜检查检测出245例癌症，是最具成本效益的方法，ICCD为53810美元。用CT替代超声仅多检测出1例癌症，ICCD为6480484美元。在亚组分析中，超声和膀胱镜检查仍然是最具成本效益的方法。该模型对所提议范围内的任何输入均不敏感。使用概率敏感性分析，超声和膀胱镜检查在100%的模拟中是主导策略。
在AMH初始评估的4种诊断方法中，肾脏超声与膀胱镜检查联合使用是最具成本效益的。使用超声代替CT作为一线诊断策略将优化癌症检测并降低与AMH评估相关联的成本。鉴于我们的研究结果，我们需要严格评估当前临床实践的适当性，并可能改变我们的指南，以反映针对AMH患者最有效的筛查策略。
