The impact of hematology electronic consultations on the management of iron deficiency

OBJECTIVES

Delays in the evaluation and treatment of iron deficiency can lead to increased disease-related morbidity and mortality. Electronic consultation (e-consult) is a referral modality that allows providers quicker access to recommendations from a specialist based on electronic chart review. While the use of e-consult is expanding in classical hematology, gaps exist in the understanding of patient outcomes related to its use for iron deficiency.

METHODS

We randomly selected 200 e-consults and 200 traditional referrals from 3,336 hematology referrals for iron deficiency at a single center. The primary outcomes of the retrospective analysis were: time to completion of the referral, and time to treatment with intravenous iron. Secondary outcomes included recurrence of iron deficiency, need for repeat e-consult, conversion to in-person evaluation, and assessment of whether the etiology of iron deficiency was addressed.

RESULTS

E-consults significantly reduced the time from referral to intravenous iron repletion (e-consult, 33 days; traditional referral, 68 days; p < .05). Assessment of the underlying etiology occurred in 70.7% of the e-consult encounters compared to 92.5% of traditional referrals (p < .05).

CONCLUSIONS

These findings highlight advantages of e-consults in improving care delivery in iron deficiency, and identifying gaps that can be improved through practice standardization to ensure equitable, high-value care.

Prognostic impact of anemia on the mortality of United Arab Emirates nationals with cardiovascular disease

Background: Cardiovascular disease is the leading cause of death worldwide. Multiple risk factors, including low hemoglobin levels, have been associated with poor outcomes in patients with cardiovascular disease. However, the long-term impact of anemia on death has not been investigated in high-risk patients in the United Arab Emirates. Therefore, this study evaluated whether anemia is a significant predictor of mortality in United Arab Emirates nationals with cardiovascular disease over 10 years.

Methods: A retrospective cohort study was conducted in an adult population of United Arab Emirates nationals with a history of cardiovascular disease, recruited from a tertiary healthcare facility. Electronic medical records between April 2008 and December 2008 were reviewed, and follow-up was conducted until December 2019. The survival functions for all-cause mortality in the presence and absence of anemia were compared using univariate Kaplan–Meier analysis with a log-rank test. The association between anemia and all-cause mortality was evaluated using a multivariable Cox regression model.

Results: A total of 224 patients were included in the follow-up for 10.5 years. At baseline, 46% of the patients had anemia, with a mean Hgb level of 105.5 ± 28.0 g/L. Patients with anemia were older (68 vs. 63 years, p = 0.001) and had a higher rate of chronic kidney disease (37.5% vs. 17.5%, p = 0.001) than those without anemia. A total of 77 (34.4%) deaths were recorded by the end of the follow-up period. Risk of all-cause mortality was significantly higher in patients with anemia than in those without (hazard ratio = 2.03, 95% confidence interval = 1.22–3.40, p = 0.006). Age and chronic kidney disease were also statistically significant predictors of death (p < 0.001 and p = 0.001, respectively).

Conclusion: Anemia is an independent predictor of all-cause mortality in United Arab Emirates nationals with underlying cardiovascular disease. Early intervention and treatment for anemia may improve clinical outcomes in this population.

Early intravenous iron administration in the Emergency Department reduces red blood cell unit transfusion, hospitalisation, re-transfusion, length of stay and costs

BACKGROUND

Moderate to severe iron deficiency anaemia is a common finding in patients admitted to the Emergency Department (ED). According to Patient Blood Management principles, intravenous iron should be the therapy of choice instead of blood transfusion for selected cases affected by chronic iron deficiency anaemia. However, this option is only rarely taken into account by physicians in the ED. As a result, in many circumstances, treatment of iron deficiency anaemia in the ED can differ from that of the Anaemia Clinic. With the aim of reducing inappropriate transfusions, and to implement intravenous iron usage, we shared a specific protocol with the ED.

MATERIAL AND METHODS

We reviewed the medical records of all subjects admitted to the ED (n=267, Post-protocol group) with hemoglobin ≤9.0 g/dL and mean corpuscular volume <80 fL in a 13-month period, except if the massive transfusion protocol was activated, and results were compared with an equivalent Pre-protocol historical cohort (n=226).

RESULTS

In comparison with the Pre-protocol series, the number of patients transfused did not change, but the appropriateness in terms of transfusion and red blood cell volume transfused improved sharply (87.0 vs 13.3%; p<0.001) with a significant increase in intravenous iron administration (50.2 vs 4.4% of cases; p<0.001). As a positive consequence, both the time spent in the ED by patients who were then directly discharged and costs per subject treated dropped by 37.9% and 59.0%, respectively. Treatment with infusion only in comparison with transfusion only led to a statistically significant Relative Risk reduction in transfusion on the ward and post-discharge transfusion of 55.6% and 44.4%, respectively.

DISCUSSION

The implementation of Patient Blood Management principles and early intravenous iron therapy in the Emergency Department have proved to be effective tools to optimise resources both in terms of units transfused and costs.

Gender differences in the impact of health literacy on hospital readmission among older heart failure patients: A prospective cohort study

AIMS

To investigate the impact of limited health literacy on 1-year hospital readmission among both older men and women with heart failure.

DESIGN

Prospective cohort study.

METHODS

A total of 286 patients with heart failure (men = 144, women = 142) aged 65 years or older at baseline from two tertiary hospitals were enrolled from June-November 2017. Patients were followed up until November 2018. The Brief Health Literacy Screening Tool was used to assess baseline health literacy. One-year readmission after discharge was assessed via medical records or telephone interview. A hierarchical logistic regression was performed.

RESULTS

The prevalence rates of limited health literacy and 1-year hospital readmission among older women were 74.7% and 35.9%, respectively, compared with 48.6% and 27.1% in older men. Limited health literacy significantly increased the risk of 1-year hospital readmission in both older men and women with heart failure. More importantly, older women with limited health literacy had a much higher risk of hospital readmission (odds ratio: 10.17, 95% confidence interval: 2.19-47.14) than did older men with limited health literacy (odds ratio: 5.27, 95% confidence interval: 2.04-13.59).

CONCLUSIONS

Our findings highlight that a baseline assessment of health literacy would help prevent unplanned hospital readmissions after discharge in both older men and women with heart failure. Health professionals should recognize that women with limited health literacy are more vulnerable to re-hospitalization than are men with limited health literacy.

IMPACT

Few studies have addressed gender differences in the link between health literacy and hospital readmission among patients with heart failure. We found that older women with limited health literacy had a much higher risk of hospital readmission than did their male counterparts. Health professionals should be aware of gender differences in health literacy in discharge planning, including self-management counselling for older patients with heart failure.

Depressive Symptoms and Physical Frailty in Older Adults With Chronic Heart Failure: A Cross-Sectional Study

Depressive symptoms and physical frailty have been reported to be predictive of adverse outcomes in individuals with heart failure (HF). Depressive symptoms could be a predisposing factor of physical frailty in older adults. Despite the high prevalence of HF, few studies on the relationship between these two factors have been performed in older adults with HF. To identify the relationship between depressive symptoms and physical frailty in HF, 190 older adults with HF were recruited from an outpatient clinic at a tertiary hospital in South Korea. The prevalence of depressive symptoms and physical frailty in older adults with HF was 30% (n = 57) and 61.6% (n = 117), respectively. Multivariate logistic regression revealed that depressive symptoms most strongly increased the risk of physical frailty after adjusting for confounding factors. Early detection of depressive symptoms might be useful to identify the status of physical frailty at the illness trajectories of HF in older adults and for judicious allocation of disease management strategies. [Res Gerontol Nurs. 2018; 11(3):160-168.].

Anemia in severe heart failure patients: does it predict prognosis?

Background

Anemia is highly prevalent in heart failure (HF) patients. However, the prevalence, clinical impact and prognostic factor of anemia in heart failure patients is widely varies. The aim of this study was to evaluate the prevalence of anemia in patients with HF, to compare baseline clinical characteristic and outcomes of severe HF patients with and without anemia admitted to Gondar University Referral Hospital (GURH), Gondar, Ethiopia.

Method

A retrospective cohort study was conducted and we assessed medical records of heart failure patients who were admitted Gondar University Referral Hospital in the period between December 02, 2010 and November 30, 2016. Kaplan Meier curve was used to analyze the survival status and log rank test was used to compare the curves. Multivariate Cox regression was used to analyze independent predictors of mortality in all HF patients. P value less than 0.05 was considered statistically significant.

Result

Three hundred and seventy patients participated in the study. The prevalence of anemia in the study cohorts was 41.90% and majority of the participants were females (64.59%). There was a significant difference in the level of hemoglobin, creatinine, and sodium among anemic and non-anemic patients. Anemic patients with HF tend to take angiotensin converting enzyme inhibitors (ACEI) less frequently. Kaplan Meier survival curves and Log rank test (P = 0.042) showed a significant difference in the prognosis of HF patients with anemia and non – anemic. More significant difference was observed (Log rank test, P = 0.001) in the study participants based on hemoglobin level. Furthermore, multivariate Cox regression showed: advanced age, levels of lower sodium and higher creatinine, and absences of medications like ACEI and Spironolactone independently predicted overall mortality.

Conclusion

HF patients with anemia tend to be older age, had lower hemoglobin and sodium level and higher creatinine value. Moreover, there was a significant difference in the prognosis between study cohorts, as anemic pateints tend to have a worse survival status . Even though, anemia is a significant risk marker, it is not an independent predictor of mortality in the current study.