title: Evaluating hematuria: impact of guideline adherence on urologic cancer diagnosis.
abstract: OBJECTIVE
  The purpose of this study was to assess physician adherence to 2001 American Urological Association (AUA) guidelines for evaluating patients with asymptomatic hematuria and its impact on the diagnosis of urologic cancer.
  
  
  METHODS
  In this institutional review board-approved retrospective study of patients with asymptomatic hematuria evaluated in a large academic health center in 2004 (allowing for long-term follow-up), we randomly selected 100 of 1771 patients with asymptomatic hematuria (52 men; mean age 54 years; 58 microscopic, 39 macroscopic, three unknown-type hematuria; median follow-up 89 months, interquartile range 33-97 months). Multivariate logistic regression assessed effects of age, sex, hematuria type, and physician specialty on guideline adherence, the primary outcome. Secondary outcome measures were variability in evaluation among physician specialists, and the proportion of patients developing urologic cancer.
  
  
  RESULTS
  Only 36 of 100 patients had a guideline-adherent evaluation, of which 5 were diagnosed with urologic cancer (median 1 month, range 0-11). No urologic cancers were diagnosed in 64 patients with nonadherent evaluations. Only evaluation by a urologist significantly predicted guideline adherence (P <.0001). Patients with gross hematuria more often underwent intravenous or computed tomography urography (P = .009); urologist evaluation more often led to intravenous or computed tomography urography (P <.0001), cystoscopy (P <.0001), cytology (P = .009), and guideline-adherent evaluation (P <.0001).
  
  
  CONCLUSIONS
  Although most physicians did not adhere to 2001 AUA guidelines when evaluating patients with asymptomatic hematuria, no urologic cancers were diagnosed in patients without guideline-adherent evaluation, barring the possibility of occult cancers. Evaluation by a urologist was the only predictor of a guideline-adherent evaluation. Future studies are needed to determine the optimal evaluation of patients with asymptomatic hematuria.
authors.affiliation: Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. Electronic address: ashinagare@partners.org.
authors.forename: Atul B
authors.initials: AB
authors.lastname: Shinagare
authors.affiliation: Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Stuart G
authors.initials: SG
authors.lastname: Silverman
authors.affiliation: Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Esteban F
authors.initials: EF
authors.lastname: Gershanik
authors.affiliation: Department of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Chang
authors.affiliation: Department of Radiology and Center for Evidence-Based Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Ramin
authors.initials: R
authors.lastname: Khorasani
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D058070:Asymptomatic Diseases; D003663:Decision Trees; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006417:Hematuria / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014571:Urologic Neoplasms / Q000150:complications* / Q000175:diagnosis*; D055815:Young Adult
keywords: Adherence to guidelines; Diagnostic evaluation; Hematuria; Variability in practice