PD09-04 TECHNOLOGY APPLICATIONS TO IMPROVE COMPLIANCE WITH HEMATURIA GUIDELINE RECOMMENDATIONS: ADDRESSING BARRIERS IN A LARGE ACADEMIC CENTER

Abstract

INTRODUCTION AND OBJECTIVE: Hematuria is associated with 5-10% risk of urothelial malignancy and is the most common symptom in bladder cancer. The American Urological Association (AUA) recommends that gross and microscopic hematuria be evaluated with cross sectional imaging and a cystoscopy. Many providers and patients are not compliant with this recommendation, as there are significant delays from the time of hematuria to the diagnosis and treatment of bladder cancer. Moreover, the barriers and facilitators for improving compliance have not been well examined. Therefore, we sought to evaluate existing practice patterns, and implemented a 3 month pilot to address the specific barriers to care to evaluate how compliance with guideline recommendations can be improved. METHODS: In cooperation with the Center for Digital Health Innovation, and after receiving approval from the University of Pennsylvania Quality Improvement institutional review board, we reviewed patient charts from June 2018 to January 2019, and evaluated existing referral systems from the Emergency Department (ED) and primary care providers to all Urology physicians and advanced practice providers. A mixed methods approach using in-depth semi-structured interviews of patients with gross or microscopic hematuria, and shadowing of patient evaluations was performed to identify potential barriers and facilitators to compliance. In total, 63 patients were interviewed for this initiative. Patients were identified according to the AUA guideline recommendations of 3+ red blood cells, without any known apparent causes such as a urinary tract infection. Utilizing these findings, a pilot project was initiated from March to June 2019 to specifically address these barriers to compliance with guideline recommendations. RESULTS: Overall, there were many points from the identification of hematuria to the evaluation where people were lost to follow up. Only 15% of patients with microscopic or gross hematuria in the ED were notified of the finding or had documented acknowledgement of the hematuria findings, only 10% were scheduled or referred to a Urologist, and only 7% actually followed through with a Urologist evaluation. For all new patient visits for hematuria, we found an alarming no-show rate of 30%, and of those who do present for the consultation, only 50% complete the full axial imaging and cystoscopy evaluation. On indepth examination, we found that 90% of the patients surveyed did not recognize the importance and need for follow-up. There was also significant stigma about the evaluation with a cystoscopy that was a barrier. Only 35% of the patient cohort had a smartphone, but 63% had a primary caregiver who helped provide rides. Forty-four percent noted difficulty with transportation as a significant barrier. Based off of patient responses, we created a calendar and infographic that describes possible reasons for hematuria, but also lists the upcoming appointments. We generated a separate order set that would automatically generate a referral order and appointment, imaging preference, and patient education material. The calendar and infographic was also sent to the patient a week before the scheduled appointment. With this simple nudge, the patient notification and education increased from 15% to 100%, and the no-show rate decreased from 30% to 9% over 3 months. CONCLUSIONS: There are significant barriers to implementing guideline-concordant care for patients with hematuria. Applying simple changes to the electronic health record and patient notifications can help to provide substantial impact in decision support, to make the right choice the easy choice for both providers and patients. By applying these simple “nudges,” there were significant and immediate improvements in guideline-concordant care and evaluation for hematuria. Future studies may provide evidence to substantiate this approach and scale to other applications for an elderly population.