jha.sciedupress.com Journal of Hospital Administration 2017, Vol. 6, No. 3 ORIGINAL ARTICLE The outpatient assessment of patients with anemia by a general internal medicine service H. McFadgen∗1, S. Couban2, S. Doucette3, A. Kreuger-Naug4, S. Shivakumar2 1Dalhousie University Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada 2Division of Hematology, Department of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada 3Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada 4Division of General Internal Medicine, Department of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada Received: April 6, 2017 Accepted: May 7, 2017 Online Published: May 11, 2017 DOI: 10.5430/jha.v6n3p41 URL: https://doi.org/10.5430/jha.v6n3p41 ABSTRACT At the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, 2,400-2,800 new outpatient referrals for hematology consultation are received annually and approximately 10% of these referrals are specifically for isolated anemia. In recent years, such referrals have been sent from hematology to general internal medicine (GIM) for assessment and management. A retrospective chart review was conducted of a cohort of 99 patients from 2013 to describe the demographics, assessment, management and outcome of these patients, as well as to inform whether this practice should continue. The median age of patients was 60.3 years (min 19.4, max 97.6) and 62% were female. The median hemoglobin level was 109.0 g/L (min 66, max 137) at the time of referral and the median wait time was 53 days (min 8 days, max 171 days). Pearson’s correlation analysis revealed that those with lower hemoglobin levels were seen more quickly. The patients had an additional 2.8 comorbidities on average, and were significantly more likely to receive non-anemia related adjustment to care with increasing number of comorbidities. A small proportion of patients (n = 5, 5.1%) were referred from GIM back to hematology, whereas 21% were referred to gastroenterology. A small number of patients (n = 5, 5.1%) underwent a bone marrow aspirate and biopsy. The most common diagnoses identified in the initial clinic letters were iron deficiency anemia (n = 59, 59.6%) and anemia of chronic disease (n = 8, 8.1%). 26.3% did not have a diagnosis identified. These findings support our practice to have patients with an isolated anemia evaluated by a general internist rather than a hematologist. Most of these patients had iron deficiency anemia or the anemia of chronic disease and received additional care for their comorbid conditions in the GIM clinic. Further work will help to define how such patients can be most effectively assessed and treated. Key Words: Anemia, Hematology, General internal medicine, Outpatient, Referral, Management 1.I NTRODUCTION iron-deficiency anemia (IDA) is the most common cause of Anemia is the most common blood disorder, with a signifi- anemia globally, followed by a number of infectious disease cant impact on morbidity and mortality.[1] In an analysis of etiologies (particularly in developing countries), while pri- global anemia burden, Kassebaum et al.[2] demonstrated that mary hematologic disorders account for a relatively small ∗Correspondence: H. McFadgen; Email: [email protected]; Address: Dalhousie University Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Published by Sciedu Press 41 jha.sciedupress.com Journal of Hospital Administration 2017, Vol. 6, No. 3 percentage of the overall cases of anemia. Aside from those the year 2013, and a follow up period of up to eighteen with chronic kidney disease (CKD), the analysis excluded months was reviewed. The patient cohort was characterized individuals with known chronic illnesses, suggesting that the using summary statistics and included median age, as well overall contribution of isolated hematologic disorders may as geographical distribution of patients. Sex was calculated have been overestimated. Given this, the question arises as as a percentage of the total study population. to which health providers are most appropriate to initially investigate, treat and follow patients found to have anemia. 2.2 Analysis of the referral process Analysis of the referral process was performed by calcu- Subspecialty care has been compared to generalist care in the lating the median length of time between receipt of refer- setting of many chronic illnesses, but there are no studies in ral by hematology and the initial GIM appointment, as the literature specifically addressing care of patients with ane- well as by a Pearson’s correlation between anemia sever- mia. While it has been postulated that patients with particular ity and time to initial appointment. Due to unavailabil- illnesses have improved clinical outcomes and adherence to ity of data, we were unable to assess the time between treatment guidelines when cared for by a subspecialist as the referral arriving in hematology and subsequently be- compared to a generalist,[3,4] the association has not always ing sent to GIM. However, the process by which refer- been shown to be a strong one.[5] Some suggest that patients rals are sent from hematology to GIM is systematic and with chronic illnesses may be most effectively cared for consistent, such that we do not believe this omission de- through co-management by both generalists and subspecial- tracts from the analysis of the referral process. Anemia ists.[6] In a systematic review of the literature on this topic, severity was classified based on World Health Organiza- Smetana et al.[7] found that in studies where subspecialty tion (WHO) criteria, where non-anemia is a hemoglobin of care was favoured, selection bias and relevant confounders > 130 g/L or > 120 g/L for men and non-pregnant women, (practice environment, physician experience, etc.) were often respectively; mild anemia is a hemoglobin of 110-129 g/L not adequately addressed, leading to further confusion in the or 110-119 g/L for men and non-pregnant women, respec- specialist versus generalist debate. tively; moderate anemia is 80-109 g/L for both men and At the Queen Elizabeth II Health Sciences Centre in Halifax, non-pregnant women, and severe anemia is a hemoglobin Nova Scotia, approximately 2,400-2,800 new outpatient re- of < 80 for both men and non-pregnant women. Baseline ferrals for hematology consultation are received each year, hemoglobin was defined as the hemoglobin level at the time and about 10% of these referrals are specifically for an iso- of referral, and was summarized in conjunction with base- lated anemia. Since isolated anemia is rarely caused by a line white blood cell (WBC) count and platelet (PLT) count. primary hematologic disease, we adopted a practice of direct- Hemoglobin level at the time of the first GIM appointment ing outpatient referrals for assessment of anemia to General was also summarized. Type of anemia was categorized as ei- Internal Medicine (GIM) specialists. This study will describe ther microcytic, normocyctic or macrocytic, as determined by the assessment, management and outcome of patients triaged the red blood cell (RBC) mean corpuscular volume (MCV) to GIM by hematology, to determine whether this practice in accordance with accepted laboratory parameters at the should continue. This project will also contribute to the ex- Queen Elizabeth II Health Science Centre. isting body of literature surrounding which specialities are most appropriate to care for patients with specific medical 2.3 Outcome of referral diagnoses. Simple statistics were used to describe the frequency with which a diagnosis was identified at the initial GIM appoint- 2.M ETHODS ment as well as the percentage of those diagnosed with iron 2.1 Data source and demographic variables deficiency anemia, anemia of chronic disease or other. In- A retrospective chart review was conducted of all ambula- vestigations measured included the number of blood tests tory patients whose referrals for an isolated anemia were ordered and frequency of bone marrow biopsies performed. sent to GIM from hematology in 2013. Clinic letters and 61 patients had sufficient follow-up data in the 18-month correspondence documents for consecutive patients referred period to be included in a sub-group analysis of patient out- to hematology and redirected to GIM in 2013 were accessed come, defined as a change in the category of anemia severity through the Nova Scotia Health Authority’s Horizon Patient as outlined above. Frequency of re-referral to hematology, Folder (HPF) system. Patients who also had other cytopenias as well as referral to gastroenterology (GI) or gynecology (thrombocytopenia or leukopenia) or who were referred to was calculated as a percentage of the total study population, hematology for reasons other than anemia were excluded. in addition to being correlated with the type of anemia (mi- Data on each patient’s first appointment was accessed from crocytic, macrocytic or normocytic). The mean number of 42 ISSN 1927-6990 E-ISSN 1927-7008 jha.sciedupress.com Journal of Hospital Administration 2017, Vol. 6, No. 3 comorbidities was evaluated from the clinic letters of each The majority of patients referred to GI had a microcytic ane- patient. The number of comorbidities was enumerated and mia (see Table3). The mean number of comorbidities per correlated with whether or not the patient received any non- patient was 2.8, and the occurrence of non-anemia related anemia related adjustment of care (e.g., changes to blood adjustment to care increased significantly with increasing pressure medication). Frequency of follow-up appointments number of comorbid diseases (see Table4). Of the 61 pa- in the year following the initial appointment was calculated tients included in the sub-group analysis of patient outcome , as a percentage of the total study population. 54.1% had an improvement in their hemoglobin that brought them up a severity level, 39.3% stayed in the same severity 3.R ESULTS category, and 6.6% dropped to a worse severity category, The characteristics of the study population are summarized eighteen months following the initial consult.