Presentation Authors: Mark Ehlers*, Chapel Hill, NC, Sheila Weinmann, Portland, OR, Michael Parchman, Seattle, WA, Marilyn Kwan, Oakland, CA, Jenny Staab, Portland, OR, David Aaronson, Oakland, CA, Matthew Wagner, Portland, OR, Matthew Nielsen, Chapel Hill, NC
Introduction: Hematuria is prevalent, with over 2 million US patients referred to urologists annually. Historical U.S. guidelines recommend CT for all adults with any degree of hematuria, whereas international guidelines recommend ultrasound, explicitly citing concerns about cost effectiveness and radiation harms. Against this backdrop, physicians in Kaiser Permanente (KP) developed a new risk-stratified guideline for hematuria, with CT restricted to patients at highest risk [gross hematuria (GH)], renal ultrasound for patients with microhematuria and risk factors [(MHRF) tobacco exposure, men, women >50 years old)] and no evaluation for nonsmoking women < 50 years old with low-risk microhematuria (LRMH)
Methods: 156,926 patients with hematuria in three health systems from 2010-2016 were identified. Two systems [KP Northern California (KPNC) and KP Northwest (KPNW)] adopted the new risk-stratified guideline in 2012-2013; the third system, KP Washington (KPWA), did not adopt any specific guideline during this period. We compared trends in CT utilization within and between systems among the three risk groups before (2010-11) and after (2014-15) guideline adoption
Results: Among patients with an episode of care for hematuria evaluation (n=81,291), the system with highest baseline CT utilization (KPNC) had stable utilization of CT for GH patients (74.7% to 73.8%, p=.2301) and substantial decreases in CT utilization for MHRF (67.6% to 44.5%, p < .0001) and LRMH (52.1% to 43.8%, p < .0001) patients after adoption of the new guideline. The system with lowest baseline CT utilization (KPNW) had guideline-concordant increase in CT utilization for GH patients (22.0% to 68.3%, p < .0001), but also modest guideline-discordant increase in CT for MHRF (21.7% to 36.7%, p < 0.001) and LRMH (21.0% to 32.1%, p=.0022) patients. KPWA had more modest changes in CT utilization (GH 55.8% to 58.9%, p=.0567; MHRF 43.0% to 48.7%, p < .0001; LRMH 42.5% to 42.0%, p=.8902)
Conclusions: Adoption of a risk-stratified guideline was associated with differential changes in utilization within and across health systems, sensitive to baseline CT utilization and patient risk factors. Substantial residual variation in utilization suggests additional opportunities for improvement.
Source of Funding: Kaiser Permanente Patient Outcomes Research to Advance Learning (PORTAL) Pilot Award