Ultrasound and cystoscopy may be most cost-effective for asymptomatic microscopic hematuria

1. In this decision-analytic model-based cost-effectiveness analysis of diagnostic tools used to investigate asymptomatic microscopic hematuria (AMH), the most frequently used diagnostic tool was computed tomography (CT) imaging.

2. However, the most cost-effective method for investigating AMH was ultrasound and cystoscopy, with a significantly lower cost per cancer detected compared with CT scan alone or in combination with cystoscopy.

Evidence Rating Level: 3 (Fair)

Study Rundown: Asymptomatic microscopic hematuria (AMH) is often how genitourinary (GU) cancers are identified. However, the diagnostic tools used for investigation of AMH may not be cost-effective and differ in their effectiveness in detecting cancer. This decision-analytic model-based cost-effectiveness analysis estimated the effectiveness, cost, and incremental cost per cancer detected (ICCD) for 4 common diagnostic approaches evaluating AMH.

The most common diagnostic tool used to investigate AMH was CT scanning, however the most cost-effective diagnostic approach was ultrasound and cystoscopy. Replacing the ultrasound with CT detected one additional cancer at an ICCD of $6,480,484. These results remained robust through subgroup and probabilistic sensitivity analysis. Strengths of this study included its thorough analysis of the literature, and also its ability to provide insight into investigation protocol for AMH, identifying cost-effective ways to investigate AMH. Limitations of this study included no long-term analysis of the outcomes of these detected cancers, and no evaluation of mortality difference across diagnostic tests.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: Performance of computed tomographic urography in diagnosis of upper urinary tract urothelial carcinoma, in patients presenting with hematuria: Systematic review and meta-analysis.

In-Depth [decision-analytic model]: This decision-analytic model-based cost-effectiveness analysis was conducted using a search of the medical literature to simulate cancer detection rates and costs associated with the evaluation of adult patients with AMH. Patients in the model had 3 or more red blood cells on urinalysis, no history of GU abnormality and concurrent negative urine culture. Effectiveness was determined by the number of cancers (composite of bladder, urothelial, upper tract urothelial, and renal cell carcinoma) detected by each diagnostic strategy. In particular, the outcomes were cancers detected, costs and ICCD per 10,000 patients evaluated for AMH. The four strategies evaluated were: CT and cystoscopy (considered the gold standard), renal ultrasound and cystoscopy, cystoscopy alone and CT alone. Statistical analysis included incremental analysis with rank open strategies, sub-group analysis (men, smoke, age ≥50 years).

The most prevalent diagnostic tool used was CT scanning, detecting 221 cancers per 10,000 patients with AMH at a cost totalling $9,300,000. Cystoscopy detected 222 cancers per 10,000 patients, with an ICCD of $10,287. The most cost-effective and effective strategy was use of renal ultrasound and cystoscopy, which detected 245 cancers per 10,000 patients with AMH at a total cost of $1,220,400, translating to an ICCD of $53,810. CT and cystoscopy detected 246 cancers, however the ICCD was $6,480,484.

Image: PD

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