Cost-effectiveness of Common Diagnostic Approaches for Evaluation of Asymptomatic Microscopic Hematuria

Abstract

IMPORTANCE 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. OBJECTIVE 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 Ն50 years) seen in the primary care or urologic referral setting. INTERVENTIONS 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. MAIN OUTCOMES AND MEASURES At termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH. RESULTS 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. CONCLUSIONS AND RELEVANCE 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.

Can Renal and Bladder Ultrasound Replace Computerized Tomography Urogram in Patients Investigated for Microscopic Hematuria?

“…Further, cost-effectiveness analysis recommended performing RBUS instead of CTU to evaluate patients with microscopic hematuria. 20 A comparison of 4 diagnostic approaches, including CT alone, cystoscopy alone, CT with cystoscopy and RBUS with cystoscopy, suggested that the combination of RBUS with cystoscopy represents the most cost-effective combination at $53,810 per each cancer detected. Replacing RBUS with CTU would cost $6,480,484 per each cancer identified.…”

Imaging for the diagnosis and response assessment of renal tumours

“…However, there is a lack of consensus regarding the optimal investigation of asymptomatic microscopic haematuria in different guidelines worldwide in terms of imaging modality (ultrasound vs. CT urography) and age threshold to prompt investigation [23]. An ultrasound (US) of the renal tract may be considered initially in low-risk young patients with non-visible haematuria as a cost-effective non-ionising technique for assessing the kidneys and bladder [24, 25]. However, US sensitivity is low for renal lesions < 1 cm (26%) [26] and it does not evaluate the collecting systems adequately; hence, CT urography (pre- and post-contrast) is recommended as a first-line tool for patients presenting with non-visible haematuria by a number of American associations [9, 11, 23, 27].…”

Microscopic haematuria in general practice

“…However, when patients with non‐visible haematuria (NVH) are considered, the situation is much less clear‐cut. Many guidelines have been prepared with a variety of protocols, ranging from ‘do nothing’ (Denmark) to computed tomography for all (USA, at a cost of $420 814 per cancer found) …”