Examining Referral Pathways for Patients With Hematuria: A Real-World Retrospective Analysis

Introduction: Follow-up for hematuria, often found incidentally on urinalysis, is critical as it may be an early sign of glomerular disease or malignancy. We evaluated nephrology and urology referral patterns for outpatients with hematuria, and factors associated with nephrology and urology referrals. Methods: This retrospective, observational cohort study leveraged electronic health record data from a large, regional health care system in Pennsylvania, USA. Outpatients with hematuria (≥1+ blood) on dipstick urinalysis from January 1, 2022, to September 30, 2022, without nephrology/urology appointments in the prior 10 years or prior genitourinary cancer were enrolled. The primary objective evaluated the proportion of outpatients with hematuria who had nephrology or urology referrals or appointments within 6 months following initial presentation. Secondary objectives evaluated concurrent proteinuria and follow-up testing patterns. Results: The mean (standard deviation) age of the 5,475 outpatients with hematuria on urinalysis was 60.5 (20.8) years, and most were female (78.0%). Overall, 774/5,475 (14.1%) patients with hematuria had a nephrology or urology referral/appointment within 6 months following presentation. Urine microscopy was performed at time of hematuria detection for 3,324/5,475 (60.7%) patients, of whom 2,388 (71.8%) had ≥3 red blood cells (RBCs) per high-power field (HPF). Repeat urinalysis was performed for 1,582/5,475 (28.9%) patients. Increased referral likelihood was associated with male sex (odds ratio: 2.3; 95% confidence interval CI: 1.9–2.7) and ≥30 RBCs/HPF on microscopy (odds ratio: 1.7; 95% CI: 1.3–2.1). Of 4,952 patients with proteinuria data, 2,375 (48.0%) had hematuria and ≥1+ protein on urinalysis, and 373/2,375 (15.7%) had nephrology (n = 58; 2.4%) and/or urology (n = 332; 14.0%) referrals within 6 months. Conclusion: This study provides insight into current outpatient hematuria management patterns. The low referral rates, particularly with concurrent hematuria and proteinuria, highlight opportunities to improve management moving forward.