Need for Improved Adherence to the 2020 AUA Microscopic Hematuria Guidelines

Objectives: The 2020 American Urologic Association (AUA) Microscopic Hematuria (MH) Guidelines implement risk stratification to focus resources on the highest risk patients and reduce unnecessary evaluation. Our primary objective was to determine provider adherence to this algorithm in the outpatient clinical setting. Secondary objective was to identify provider- and patient-specific factors that affected adherence.

Methods: This cross-sectional study evaluated management of patients diagnosed with MH at a single academic medical center between 1/1/21 and 12/31/22, with 6-month follow-up. Eligible patients included adults ≥ 18 years of age with ≥ 3 red blood cells per high power field on urinalysis (UA) in an outpatient clinical setting ordered by a subspecialist provider (Urogynecology, Urology), or primary care provider (PCP; Internal Medicine, Family Medicine, General Gynecology). Patients were excluded for: gross hematuria, urinary tract infection, pregnancy or postpartum status, mucosal contamination, urinary retention requiring self-catheterization, urinary diversion, genitourinary surgery (within 3 months), ureteral stent or nephrostomy tube (within 12 months), prior urothelial cancer or pelvic radiation, prior MH workup (within 3 years), and death within the study period. Retrospective data collection was performed using automated and manual data extraction from electronic medical records. Data were analyzed using descriptive statistics and multivariable logistic regression.

Results: Three hundred two patients met inclusion criteria. Mean age was 58.4 years (SD 18.7), predominantly female (77.5%), white (94.7%), and non-Hispanic (96.7%). Based on AUA risk stratification, 59.9% were high-risk, 33.1% intermediate-risk, and 7.0% low-risk. PCPs ordered 76.5% of the diagnostic urinalyses, while subspecialists ordered 23.5%. Providers included 116 attending physicians (38.4%), 159 advanced practice providers (52.6%), and 27 residents/fellows (9.0%).

Only 18.9% of high- and intermediate-risk patients received the correct imaging order. Subspecialists had 4.92 greater odds of ordering the correct imaging compared to PCPs (95%CI 2.46–10.0, p< 0.001). Of all patients, 66.6% did not receive any workup for MH, and only 12.3% received the correct AUA-recommended workup. Only 14.4% of high-risk patients received the recommended MH workup. Patients with UA ordered by a subspecialist had 15.5 greater odds of receiving the correct workup compared to those with UA ordered by a PCP (95%CI 6.35–41.8, p< 0.001). Eighteen patients received potentially unnecessary CT radiation. Urothelial cancer was detected in one high-risk patient with correct workup 4.9 months following UA, and in two high-risk patients with delayed workup at 17.6 and 26.0 months after UA.

Conclusions: Adherence to the 2020 AUA guidelines was suboptimal for providers in all specialties, but particularly for PCPs. Guideline awareness, cross-specialty communication, and clinical decision tools may improve diagnosis and appropriate management of MH. Subspecialist providers can advocate for improved guideline utilization to optimize patient-centered outcomes.

Table 1 & 2 Footnote: Percentages reflect proportion of patients with provider/patient factor (row) who meet MH evaluation criteria listed (column header).