Variation in the Intensity of Hematuria Evaluation: A Target for Primary Care Quality Improvement
Variation in the Intensity of Hematuria Evaluation: A Target for Primary Care Quality Improvement
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DOI：
10.1016/j.amjmed.2014.01.010
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发表时间：
2014-07-01
影响因子：
5.9
通讯作者：
Barocas, Daniel A.
中科院分区：
文献类型：
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作者：
Friedlander, David F.;Resnick, Matthew J.;Barocas, Daniel A.
背景：血尿是膀胱癌常见的临床表现，也是膀胱癌最常见的临床表现。美国泌尿科协会建议年龄超过35岁的患者进行膀胱镜检查和腹部盆腔成像。尽管如此，只有不到一半的出现血尿的患者接受了适当的评估。我们试图确定与评估新诊断的血尿患者相关的临床和非临床因素。方法：我们进行了一项回顾性队列研究，使用索赔数据和实验室数据。主要暴露在实践场所，作为非临床的、潜在的可修改的变异源的替代品。主要结果是在血尿诊断后180天内行膀胱镜检查或腹部盆腔造影。我们模拟了临床和非临床因素与适当的血尿评估之间的关系。结果：我们确定了2455名年龄在40岁或以上的初级保健患者，在没有其他解释性诊断的情况下，他们在2004-2012年间被诊断为血尿；13.7%的患者在180天内接受了膀胱镜检查。多因素Logistic回归分析显示，接受和未接受评估的患者在年龄、性别和抗凝剂使用方面存在显著差异(P<；.001，P=.036，P=.028)。训练现场的加入提高了各模型的预测性区分度(P<；.001)。评估与较高的泌尿生殖道肿瘤诊断率相关。结论：血尿患者很少接受完全评估。虽然已确定的恶性肿瘤危险因素与诊断性检测的使用增加有关，但与风险无关的因素，如实习地点，也解释了显著的差异。实践现场之间的不一致是不可取的，可能会受到质量改进干预的影响。(C)2014 Elsevier Inc.保留所有权利。
BACKGROUND: Hematuria is a common clinical finding and represents the most frequent presenting sign of bladder cancer. The American Urological Association recommends cystoscopy and abdomino-pelvic imaging for patients aged more than 35 years. Nonetheless, less than half of patients presenting with hematuria undergo proper evaluation. We sought to identify clinical and nonclinical factors associated with evaluation of persons with newly diagnosed hematuria.METHODS: We performed a retrospective cohort study, using claims data and laboratory values. The primary exposure was practice site, as a surrogate for nonclinical, potentially modifiable sources of variation. Primary outcomes were cystoscopy or abdomino-pelvic imaging within 180 days after hematuria diagnosis. We modeled the association between clinical and nonclinical factors and appropriate hematuria evaluation.RESULTS: We identified 2455 primary care patients aged 40 years or more and diagnosed with hematuria between 2004 and 2012 in the absence of other explanatory diagnosis; 13.7% of patients underwent cystoscopy within 180 days. Multivariate logistic regression revealed significant variation between those who did and did not undergo evaluation in age, gender, and anticoagulant use (P < .001, P = .036, P = .028, respectively). Addition of practice site improved the predictive discrimination of each model (P < .001). Evaluation was associated with a higher rates of genitourinary neoplasia diagnosis.CONCLUSIONS: Patients with hematuria rarely underwent complete evaluation. Although established risk factors for malignancy were associated with increasing use of diagnostic testing, factors unassociated with risk, such as practice site, also accounted for significant variation. Inconsistency across practice sites is undesirable and may be amenable to quality improvement interventions. (C) 2014 Elsevier Inc. All rights reserved.