Quality and cost assessment of Canadian Urological Association microscopic hematuria guidelines in clinical practice: Turning urine into gold

Introduction: Asymptomatic microscopic hematuria (AMH) is defined in the Canadian Urological Association (CUA) guidelines as >2 red blood cells (RBCs) per high-powered field (hpf). Our objective is to evaluate guideline adherence for AMH at our centre. Secondarily, we aim to identify areas of the guideline that can be optimized. Methods: We retrospectively reviewed 875 consecutive adults referred to two urologists for hematuria from June 2010–2016. Patient characteristics, risk factors, and outcomes were added to an encrypted REDCap database. Evaluation of microscopic hematuria reporting was performed by analyzing 681 urine samples reported as 1–5 RBC/hpf. Healthcare costs were obtained from Alberta Health Services (AHS), Data Integration and Management Repository (DIMR), and Alberta Society of Radiologists (ASR). Results: Of the 875 patients referred with hematuria, 400 had AMH. Overall, 96.5% completed evaluation consistent with the CUA guideline. The incidence of pathology requiring surgical intervention was 21/400 (5%), with a 0.8% rate (3/400) of urothelial cell carcinoma (UCC) (non-invasive, low-grade). No malignancy was found in non-smokers with normal cytology, normal imaging and <50 RBC/hpf; 44% had AMH in the 1–5 RBCs/hpf range. Only 41% (279/681) of urine samples categorized as 1–5 RBCs/hpf had guideline-defined microscopic hematuria. By changing local microscopic hematuria reporting to differentiate 1–2 and 3–5 RBCs/hpf, we estimate $745 000 in annual savings. Conclusions: At our centre, CUA AMH guideline adherence is high. We did not find malignancy in non-smokers with normal cytology, imaging, and <50 RBC/hpf. We identified and changed regional microscopic hematuria reporting to fit the CUA definition, eliminating unnecessary investigations and healthcare costs.