To evaluate urologic consultations, bladder cancer (BCa) distribution, and estimated costs of alternative evaluation strategies for microhematuria (MH) at a Veterans Affairs (VA) center.

We retrospectively studied Veterans with MH at Jesse Brown VA (2021-2024). Patients were risk-stratified by MH severity (low: 3-10 red blood cells per high-powered field [RBC/hpf], intermediate: 11-25, high: ≥26) and age (low: 18-39, intermediate: 40-59, high: ≥60). The primary outcome was urology consultation. BCa detection was assessed across risk groups, and procedural costs compared across guideline-based and alternative strategies.

Among 1046 veterans, 71.6% received a urology consult. When stratified by MH-based risk, 69.5% of low-risk, 70.5% of intermediate-risk, and 75.9% of high-risk patients received a consult. Neither MH- nor age-based risk predicted consultation. BCa was detected in 7 high-risk patients (0.7%). Raising the diagnostic threshold to ≥26 RBC/hpf reduced total costs ($382,939 vs $1015,029) but increased costs per patient evaluated ($1201 vs $971).

Urologic evaluation among Veterans with MH is common, yet BCa detection is low and concentrated in high-risk individuals. Current referral patterns may overuse resources for low-risk patients. Raising diagnostic thresholds and substituting ultrasound for CT in low-risk patients could reduce costs. Future multi-center studies should validate these findings and examine overuse of cystoscopy and imaging for low-risk patients.