The presence of blood in the urine, or "hematuria", may herald the presence of urologic malignancy such as bladder cancer or kidney cancer;benign urologic disease such as kidney stones (nephrolithiasis), urinary tract infection;or intrinsic renal disease, such as glomerulonephritis. The proper evaluation of patients with hematuria is essential to identify the 1 person in 10 who may have a life-threatening malignancy or other treatable condition. Chief among these conditions is bladder cancer (BC), because of its high incidence and lethality. Guidelines from the American Urological Associate (AUA) and the National Cancer Collaborative Network (NCCN) call for evaluation of persons presenting with suspicion for urothelial carcinoma using office cystoscopy (endoscopic evaluation of the bladder) to rule out BC and, in many instances, an imaging study of the kidneys and ureters to rule out other malignancies. There is some evidence of insufficient adherence to guidelines for surveillance of patients with BC, but there is a gap in the evidence with respect to the initial evaluation of those suspected of harboring BC. Delayed or incomplete evaluation indicates poor adherence to published guidelines, and could contribute to sub-optimal BC outcomes. In fact, one theory, which has yet to be tested, is that racial variation in adherence to evaluation guidelines could explain the racial paradox in BC: while BC is more common among Whites, African-American patients present with higher-stage disease, and have a higher likelihood of disease-specific mortality. We propose several approaches to determine the current quality of evaluation of patients with hematuria, to identify racial variation in the timely and complete evaluation of hematuria and to determine the underlying reasons for such variation. First, we will look broadly at the Medicare dataset to determine the frequency of use of cystoscopy and imaging for patients with hematuria, and investigate whether there are racial differences in their use on a national level. Second, we will use a well-characterized prospective cohort of over 86,000 economically disadvantaged and racially diverse persons in the Southeastern US (The Southern Community Cohort Study) in order to identify the factors that may underlie racial variation in the timely and complete workup of hematuria, such as socio-economic status, educational attainment, healthcare access indicators. The remaining unexplained variation may be amenable to educational interventions among primary care providers. The ultimate aim of the proposed study is to identify gaps in the quality of care for patients with hematuria, which will become targets in a planned interventional study through a multi-center quality collaborative in which we participate.

Public Health Relevance

The timely and complete evaluation of patients presenting with blood in the urine (hematuria) is necessary to identify the 1 in 10 patients who may harbor a life-threatening malignancy, such as bladder cancer, or other treatable condition. While there are clear clinical guidelines regarding the evaluation of patients with hematuria, there is no data to indicate the level of adherence to these guidelines, and racial variation in adherence could explain variation across patient groups in bladder cancer stage at diagnosis and downstream outcomes. Therefore, the proposed study aims to identify variation in the timely and complete evaluation of hematuria in two distinct datasets covering broad segments of the population, in order to develop targets for interventional studies aimed at improving the quality of care of these patients.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Small Research Grants (R03)
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Special Emphasis Panel (ZCA1-SRLB-B (O1))
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Kobrin, Sarah
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Vanderbilt University Medical Center
Schools of Medicine
United States
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Friedlander, David F; Resnick, Matthew J; You, Chaochen et al. (2014) Variation in the intensity of hematuria evaluation: a target for primary care quality improvement. Am J Med 127:633-640.e11