NE-AUA 2006 Annual Meeting, September 28 - 30, 2006, The Westin Hotel & Rhode Island Convention Center Providence, Rhode Island
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A Cost Comparison of the Diagnostic Modalities Used in the Detection of Urothelial Carcinoma in Patients Undergoing Evaluation for Hematuria.
Boback M. Berookhim, BA, Amanjot S. Sethi, MD, C. Charles Wen, MD, Jing Ciu, Richard K. Babayan, MD, Louis S. Liou, MD.
Boston University School of Medicine, Boston, MA,

Background: The incidence of cancer of the urinary bladder is estimated to be 63,210 in the United States in 2005. Studies have shown that 6% to 13% of hematuria evaluations yield diagnoses of urothelial carcinoma (UC) and upper tract tumors, translating to 500,000 to 1,000,000 hematuria evaluations per year. The evaluation of hematuria costs the United States $520 million to $1.09 billion per year. This study investigates the respective costs, sensitivities and specificities of cystoscopy, CT scan, urine cytology and NMP-22 in the detection of UC.
Methods: A retrospective review was performed on the last 373 patients who underwent evaluation for gross or microscopic hematuria. All patients received a cystoscopy and CT urogram, and urine was obtained for NMP-22 and cytology data. The Medicare reimbursement rates as of May 2005 were obtained for each of the above modalities. The McNemar test was used for pair-wise comparison of sensitivity and specificity.
Results: Cystoscopy was more sensitive than CT scan, cytology and NMP-22 in the diagnosis of UC (p<0.05). Combining cystoscopy with cytology yielded an overall sensitivity and specificity of 96% and 97%, respectively (Total charge $397.41), with no statistically significant improvement over cystocopy alone. Cystoscopy in combination with CT ($1026.41) or NMP ($414.70) did not prove to show any advantage over cystoscopy alone, and decreased test specificity in a statistically significant manner.

Results of Test Comparisons

Test

Sensitivity (95% CI)

Specificity (95% CI)

PPV

NPV

Cost (Dollars)

Cytology

27%
(12-48%)

100%
(99-100%)

100%

95%

11.78

NMP-22

73%
(52-88%)

76%
(71-80'%)

19%

97%

29.07

Cystoscopy

96%
(79-97%)

97%
(95-99%)

74%

99%

385.63

CT Urogram

62%
(41-80%)

98%
(96-99%)

67%

97%

640.78

Cystoscopy or Cytology

96%
(80-99%)

97%
(95-99%)

74%

99%

397.41

Cystoscopy or NMP-22

96%
(80-99%)

90%
(87-93%)

42%

99%

414.70

Cystoscopy or CT

96%
(80-99%)

96%
(93-98%)

63%

99%

1026.41


Conclusions: In our series, cystoscopy proved to be the most effective modality at diagnosing UC, with 96% sensitivity and 97% specificity. This data suggests that a CT scanís poor sensitivity may not contribute to the diagnosis of UC, and imposes unnecessary expenses on the healthcare system. Although there were no cases of upper tract UC in this series, its potential risk still warrants an upper tract evaluation. In our patient population, the utilization of less-expensive modalities, such as ultrasound ($92.74), may prove to be more cost-effective than CT scan when used in conjunction with cystoscopy and urinary markers in the evaluation of hematuria.


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