Delayed and Incomplete Hematuria Evaluation Across Diverse Populations: A Prospective National Study

PURPOSE: To assess whether race, ethnicity, gender, and social determinants of health are associated with differences in evaluation after microscopic or gross hematuria. MATERIALS AND METHODS: We conducted a prospective cohort study using All of Us, a national, multicenter database. EHR data from 2016-2023 were analyzed. Patients with microscopic or gross hematuria after enrollment were included, while those with UTIs, urolithiasis, pregnancy, or prior genitourinary malignancy were excluded. Outcomes were time to receipt of evaluation, defined as cystoscopy, genitourinary imaging, or both. Time-to-event analyses including Kaplan-Meier estimates and multivariable Cox regression with interaction analysis were performed. RESULTS: Our cohort (16,015 patients) is 50% White, 21% Hispanic, 18% Black, and 11% 'Other' race. 15% of patients presented with gross hematuria. Over the observation period of more than 6 years, the total number patients evaluated for either cystoscopy or imaging was 3,491, with an overall cumulative incidence of 0.43 estimated using the Kaplan-Meier method. Females had a lower overall cumulative incidence of cystoscopy than males in both microscopic hematuria (0.056 vs. 0.12, adjusted Hazard Ratio-aHR 0.53 [0.42-0.66]) and gross hematuria (0.13 vs. 0.23, aHR 0.59 [0.44-0.79]); similar gender disparities recurred for imaging and complete evaluation. After adjustment for social determinants of health, racial differences varied by severity and outcome, with Hispanic patients demonstrating a decrease in cystoscopy rates among patients with more severe microscopic hematuria (aHR 0.80 [0.64-0.99]). CONCLUSIONS: Hematuria evaluation was infrequent and inequitable in this diverse national cohort, with persistent disparities by gender and race with significant delays. Interventions to improve referral and guideline adherence are needed.