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UPJ INSIGHT Deimplementation of Computed Tomography Urogram for Low- to Intermediate-risk Microscopic Hematuria
By: Sarah A. Birken, PhD, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Richard Matulewicz, MD, MSCI, MS, Memorial Sloan Kettering Cancer Center, New York, New York; Ram Pathak, MD, Mayo Clinic, Rochester, Minnesota; Cheyenne R. Wagi, MA, MPH, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Alexandra G. Peluso, MS, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Richa Bundy, MPH, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Lauren Witek, MS, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Bridget Krol, BS, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Michael L. Parchman, MD, MPH, Kaiser Permanente Washington Health Research Institute, Seattle; Matthew Nielsen, MD, MS, School of Medicine, University of North Carolina at Chapel Hill; Ajay Dharod, MD, FACP, Wake Forest University School of Medicine, Winston-Salem, North Carolina, Wake Forest Center for Healthcare Innovation, Winston-Salem, North Carolina, Wake Forest Center for Biomedical Informatics, Winston-Salem, North Carolina | Posted on: 25 Oct 2023
Birken SA, Matulewicz R, Pathak R, et al. Toward the deimplementation of computed tomography urogram for patients with low- to intermediate-risk microscopic hematuria: a mixed-method study of factors influencing continued use. Urol Pract. 2023;10(5):511-519.
Study Need and Importance
Until 2020, the AUA recommended that all patients with microscopic hematuria be evaluated using computed tomography urogram (CTU). In 2020, the AUA risk-stratified its guidelines, recommending ultrasound instead of CTU for patients with low- to intermediate-risk microscopic hematuria. Accordingly, continued use of CTU for these patients represents low-value care. To support the selection of strategies to support risk-stratified microscopic hematuria evaluation, we assessed changes in clinical practice following the AUA’s 2020 guideline revision and factors influencing clinicians’ microscopic hematuria evaluation approach.
What We Found
In this mixed-method study, our quantitative results found declines in low-value CTU following the AUA’s revision of microscopic hematuria evaluation guidelines, with more substantial declines among urology providers than nonurology providers, although these differences were not statistically significant (see Table). Our qualitative findings corroborated quantitative findings by suggesting that urologists’ access to revised guidelines, which emphasize the risk of CTU, and nonurology providers’ deference to urology providers contributed to differences in CTU following guideline revisions.
Table. Low-value Computed Tomography Urogram Orders
| Pre-guideline change in CTs ordered for low to intermediate risk, No. (%) | Post-guideline change in CTs ordered for low to intermediate risk, No. (%) | |
|---|---|---|
| Urology | 101 (55.2a) | 39 (35.5) |
| Nonurology | 34 (69.4) | 22 (51.2) |
| Total | 135 (58.2b) | 61 (39.9) |
| Abbreviations: CT, computed tomography. aPercent of low-/intermediate-risk CTs, of all CTs, ordered by provider type. bPercent of all CTs (n=232) low, intermediate, or high risk, ordered by either provider type. |
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Limitations
We used retrospective data from in a single academic tertiary medical center in the southeastern US; findings may not generalize to other institutions. We were unable to classify 328 (46%) patients due electronic health record data limitations, potentially yielding more conservative estimates of AUA guideline adherence. Our qualitative findings may not be transferrable to many providers; despite significant recruitment efforts, we were unable to interview as many providers as planned.
Interpretation for Patient Care
Our findings suggest high-leverage, evidence-based strategies to reduce low-value care, including disseminating guidelines to nonurology providers and using algorithms to support clinical decision-making. Issuing guidelines with implementation guidance may facilitate the deimplementation of low-value urological care that guideline developers seek.
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