eConsult Provides a Novel Opportunity to Evaluate Hematuria Referrals for Medicaid Patients in the "Real-World" Community.

INTRODUCTION: We utilized an eConsult program to assess the appropriateness and completeness of hematuria evaluation among one of the largest Medicaid networks in California, the Inland Empire Health Plan. METHODS: We retrospectively reviewed all hematuria consults from May 2018 to August 2020. Patient demographic and clinical data were extracted from the electronic health record and dialogues between primary care provider and specialist including laboratory results and imaging. We calculated the proportions of imaging types and the outcome of the eConsults among patients. χ2 and Fisher's exact tests were used for statistical analysis. RESULTS: A total of 106 hematuria eConsults were submitted. Primary care provider evaluation for risk factors rates were low: 37% gross hematuria, 29% voiding symptoms/dysuria, 49% other urothelial risk factors or benign etiology, and 63% smoking. Only 50% of all referrals were deemed appropriate based on a history of gross hematuria or ≥3 red blood cells/high-power field on urinalysis without evidence of infection or contamination. Thirty-one percent of patients received a renal ultrasound, 2.8% received CT urography, 5.7% received other cross-sectional imaging, and 64% received no imaging. By the conclusion of the eConsult only 54% of patients were referred for a face-to-face visit. CONCLUSIONS: The use of eConsults allows for urological access in the safety-net population and presents a means to assess the urological needs in the community. Our findings suggest eConsults represent an opportunity to reduce the morbidity and mortality associated with hematuria among safety-net patients who are otherwise less likely to receive a proper evaluation.

When is a Seminoma not a Seminoma? The Incidence, Risk Factors and Management of Patients With Testicular Seminoma With Discordant Elevated Serum Alpha-fetoprotein.

OBJECTIVE: To describe the incidence, clinical and demographic factors, and treatment patterns associated with discordant elevated alpha-fetoprotein (AFP) findings in patients with pure seminomatous histology. METHODS: We queried the National Cancer Database to identify patients with testicular germ cell tumors (GCT) diagnosed in 2011-2015. Patients were grouped based on histologic diagnosis and pre-operative serum AFP level. RESULTS: Of 18,616 patients diagnosed with testicular GCT, 53% (N = 9,849) had pure seminomatous histology, of whom 8.3% (N = 821) had an elevated serum AFP pre-operatively. Non-white patients with seminoma were more likely to have a pre-op elevated AFP (OR 1.42; 95% CI: 1.10-1.83); patients treated at higher volume centers were less likely to have a pre-op elevated AFP (0.66, 95% CI: 0.53-0.83). Patients with seminoma with elevated AFP received adjuvant radiation more frequently than those with NSGCT (Stage I: 15% vs 0.2%, P <.01; Stage II: 21.9% vs 0.1%, P <.01) and less frequently underwent retroperitoneal lymph node dissection (RPLND) (Stage 1: 1.9% vs 11.1% P <.01; Stage II: 8.8% vs 17.4%, P <.01). CONCLUSION: The detection of elevated serum alpha-fetoprotein (AFP) in patients with pure seminomatous testicular germ cell tumors (GCT) is a discordant finding that implies the presence of occult non-seminomatous GCT (NSGCT) elements. 8% of patients with pure seminomatous GCTs had diagnostically discordant elevated pre-operative AFP levels. Despite recommendations to manage these patients as NSGCT, patients with seminoma and elevated AFP were managed in a fashion comparable to those with seminoma and normal AFP levels.