Guideline Adherence for hematuria evaluation in the real world: Evidence from 1.9 million patients in Epic COSMOS

Document Type

Conference Proceeding

Publication Date

3-1-2026

Publication Title

Eur Urol

Keywords

Urology & Nephrology

Abstract

Introduction & Objectives: Hematuria is a well-recognized warning sign in urology, potentially indicating underlying malignancy of the urinary tract. Current guidelines recommend a risk-stratified diagnostic workup, typically including cystoscopy and upper tract imaging, to ensure timely detection of urologic cancers. However, adherence to these recommendations in real-world practice remains poorly characterized. We aimed to evaluate compliance with guideline-recommended hematuria workup and to identify demographic and clinical factors associated with receiving appropriate evaluation. Materials & Methods: Data used came from Epic Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 300 million patient records from over 1,700 hospitals and 40.7 thousand clinics as of August 2025. Adults with a diagnosis of micro- or macrohematuria were included. Patients with prior urologic cancer (2 years), infection (4 weeks), or urologic procedure/visit (6 weeks) before diagnosis were excluded. Low-risk patients were removed per year-specific criteria. Guideline-adherent workup was defined as cystoscopy or upper tract imaging within 6 months from hematuria diagnosis. Multivariable logistic regression identified demographic, clinical, and socioeconomic predictors of appropriate evaluation. Results: Among 1,973,586 patients with a hematuria diagnosis, only 23.4% (n=462,579) underwent a guideline-recommended evaluation. Overall, 41.4% received cystoscopy and 69.0% underwent upper tract imaging. Patients who received workup were older (mean 62 vs. 60 years), more frequently male (57.9% vs. 48.5%), and had higher comorbidity burden (CCI > 4: 34.8% vs. 25.2%, all p < 0.001). They were more likely to be smokers (67.6% vs 64.3%) and married (all p<0.001). In contrast, Black patients and those from areas with higher social vulnerability were less likely to receive evaluation (p < 0.001 for all). In multivariable analysis, male sex (OR 1.38, 95% CI 1.37–1.39), rural residence (OR 1.17, 95% CI 1.16–1.18), smoking (OR 1.07, 95% CI 1.06–1.07), and higher Social Vulnerability Index (OR 1.06 per 1-unit increase, 95% CI 1.04–1.07) were independently associated with receiving workup, whereas Black race (OR 0.97, 95% CI 0.96–0.98) predicted lower adherence. Overall, 9.7% of patients were subsequently diagnosed with a urologic malignancy, including 6.1% with bladder cancer. Conclusions: Across a nationwide cohort of nearly two million patients, only one in four received evaluation consistent with hematuria guidelines. Despite the relatively low prevalence of urologic malignancy, the detection rate of bladder cancer remains clinically meaningful. These findings highlight a substantial real-world gap in adherence to guideline-based hematuria evaluation and underscore the need for system-level strategies to ensure timely and equitable diagnostic workup.

Volume

89

First Page

1

Find It @ Sladen

Share

COinS