Matulewicz Richard S, Tsuruo Sarah, King William C, Nagler Arielle R, Feuer Zachary S, Szerencsy Adam, Makarov Danil V, Wong Christina, Dapkins Isaac, Horwitz Leora I, Blecker Saul
Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, New York.
Department of Population Health, NYU Grossman School of Medicine, New York, New York.
J Urol. 2025 May;213(5):558-567. doi: 10.1097/JU.0000000000004436. Epub 2025 Jan 24.
We aimed to determine whether implementation of a clinical decision support (CDS) tool integrated into the electronic health record of a multisite academic medical center increased the proportion of patients with AUA "high-risk" microscopic hematuria (MH) who receive guideline-concordant evaluations.
We conducted a 2-arm cluster randomized quality improvement project in which 202 ambulatory sites from a large health system were randomized to either have their physicians receive at time of test results an automated CDS alert for patients with high-risk MH with associated recommendations for imaging and cystoscopy (intervention) or usual care (control). Primary outcome was met if a patient underwent both imaging and cystoscopy within 180 days from MH result. Secondary outcomes assessed individual completion of imaging, cystoscopy, or placement of imaging orders.
There were 917 patients randomized to intervention (n = 476) or control (n = 441) arms between October and December 2021. The percentage of eligible patients for whom the alert correctly triggered in the intervention arm was 83%. Primary outcome was achieved in 0.6% vs 0.9% (relative risk 0.69; 95% CI 0.15, 3.10) of patients in the intervention and control arms, respectively. Patients in the intervention and control groups had similar rates of completed imaging (17.7% vs 14.7%) and cystoscopy (1.5% vs 0.9%). Those in the intervention arm had a higher likelihood of CT urogram order (5.5% vs 1.1%, = .003) and a nonsignificant increase in urology evaluation (11.1% vs 7.5%, = .09).
Implementing an electronic health record-integrated CDS tool to promote evaluation of patients with high-risk MH did not lead to improvements in patient completion of a full guideline-concordant evaluation. The development of an algorithm to trigger a CDS alert was demonstrated to be feasible and effective. Further multilevel assessment of barriers to evaluation is necessary to continue to improve the approach to evaluating high-risk patients with MH.
