Standard 12 Management of Anemia in Non-Surgical Patients

1. Standard 12Management of Anemia in Non-Surgical Patients Irwin Gross, M.D. Medical Director Patient Blood Management Eastern Maine Medical Center

2. Disclosures • None

3. Standard 12Management of Anemia in Non-Surgical Patients • There is a program to facilitate identification, diagnosis and management of anemia in non-surgical patients served by the organization. Anemia is actively managed to improve clinical outcomes and reduce the likelihood of transfusion should the patient require hospitalization. (See related Standard 6)

4. Why add this new Standard ?

5. It doesn’t say: “Manage anemia only in surgical patients.”

6. Anemia, Bleeding, and Transfusion Increased Mortality and Mortality Anemia Bleeding Transfusion Early recognition and treatment of anemia is key!!

7. Prevalence of Anemia and Iron Deficiency • Prevalence of iron deficiency • Children age 1-2 years: 14% • Children age 3-5 years: 4% • Females age 12-19 years: 9% • Females age 20-49 years: 9% • There are 80 million women between ages 12-49; therefore 7.2 million who are iron deficient! National Health and Nutrition Examination Survey NHANES III

8. Prevalence of Anemia in “Older” Persons Size of symbol proportional to size of cohort

9. Prevalence of Anemia and Iron Deficiency • Overall prevalence of anemia in U.S. much higher than iron deficiency anemia alone • (At least) 11% of men and 10.2% of women over age 65 are anemic ! {Blood. 2004;104(8)} • Patients over the age of 65 are most likely to be hospitalized, have CKD, CHD, have surgery and most likely to be transfused • Previously undiagnosed anemia is common in elective and emergent surgical patients

10. Prevalence of Anemia and Iron Deficiency • Most common underlying causes include: • Iron deficiency • Vitamin B12 deficiency • Chronic kidney disease • Other chronic inflammatory diseases • Folate deficiency (uncommon in U.S.) • Unexplained Anemia of the Elderly (UAE) • Anemia associated with the causes listed above are treatable !!

11. Prevalence of Anemia in Chronic Heart Failure • Meta-analysis of 34 studies from 2001-2007 involving over 150,000 patients1 • Prevalence of anemia was 37.2% • Study of Anemia in a Heart Failure Population (STAMINA-HFP) registry2 • Prevalence of anemia was 34% in a cohort of 1076 patients using the WHO definition of anemia 1) J Am CollRadiol. 2008;52:818-827 2) Am Heart J. 2009;157:926-932

12. Incidence of Anemia in Chronic Heart Failure • Studies of Left Ventricular Dysfunction (SOLVD) trial found a 9.6% incidence of new-onset anemia at one year1 • Recent large trials - Carvedilol or Metoprolol European Trial (COMET)2 and Valsartan in Heart Failure (Val-HeFT)3 -observed higher one-year incidence rates of anemia of 14.2% and 16.9% respectively 1) Heart Failure Clinic. 2010;6:373-383 2) Eur Heart J. 2006;27:1440-1446 3) Circulation. 2005;112:1121-1127

13. Time course of anemia during six months follow up following ICU discharge • Patients without anemia at admission but with moderate to severe anemia at discharge • 53% of patients still anemic at 6 months (10 of 19) Patients with persistent anemia had elevated levels of inflammatory cytokines Bateman AP, et al

14. Standard 12Management of Anemia in Non-Surgical Patients • There is a program to facilitate identification, diagnosis and management of anemia in non-surgical patients served by the organization. Anemia is actively managed to improve clinical outcomes and reduce the likelihood of transfusion should the patient require hospitalization. (See related Standard 6)

15. The Intent of Standard 12 To encourage the recognition, diagnosis and treatment of anemia across the full spectrum of care – outpatient, inpatient, and post-discharge – as an integral part of a comprehensive patient blood management program

16. Are outpatients treated for anemia in a clinic setting at your hospital? If so, where are they treated? Who provides medical oversight for the program if one exists?

17. Is there a process for referring inpatients to a program for management of anemia after discharge? How does the attending physician communicate with the patient blood management program or outpatient anemia program to arrange for post-discharge anemia treatment? How is the primary care provider notified?

18. How has your organization made your provider community aware of the existence of your anemia management program? Have you seen an increase in the number of patients seen in your anemia management program?

20. What is the mechanism for providers in your community to refer patients to your clinic? Have you made the referral process easy for providers to access and use?

21. Describe your treatment strategy for iron deficiency anemia? For anemia of chronic inflammation? For chronic kidney disease? What process was followed in developing your treatment guidelines and protocols?

22. In the past two years, what have you done to make the specialist provider community aware of the need to identify and treat anemic patients within their specialty?

23. What is the relationship between your outpatient anemia clinic and the hematology/oncology services in your community? Is there a mechanism for referring patients seen in the anemia clinic who are found to have primary bone marrow pathology including malignancy, to the hematology/oncology clinic?

24. What metrics are used to follow and evaluate your anemia management program? How do you know patients are benefiting from anemia management?

29. Role of the Quality Guide • A roadmap to full compliance with the Clinical and Administrative Standards • A tool to guide hospitals in developing a comprehensive patient blood management program