Closing the Gap: A Multidisciplinary Quality Improvement Project Improving Diagnosis and Care for Women with Undiagnosed Bleeding Disorders

Background: Research has shown that irrespective of the hemostatic challenges women face during their lives, they are less likely to be referred to a hematologist than their male counterparts and are managed primarily from a symptomatic standpoint. Women face many barriers to diagnosis including lack of provider awareness of bleeding disorders and the work-up required to make a diagnosis. Unique to menstruating women, there is overlap between many gynecologic diagnoses that can mimic a bleeding disorder; hence, leading to misdiagnosis and treatment targeted towards symptomatology as opposed to establishing a diagnosis. There also remains a major barrier for many women in the United States for diagnosis due to lack of access to care and health literacy. In Eastern North Carolina, compared to United States averages, we have high rates of uninsured, higher rates of poverty, higher patient to primary care physician ratios, and a higher rate of minority patients.

Methods: We report on an ongoing, prospective quality improvement project funded by the Foundation for Women and Girls Bleeding disorders that aims to improve the identification of concurrent bleeding disorders in women presenting to the gynecology clinic with excessive vaginal bleeding. During routine gynecology patient encounters, patients are consented and screened utilizing the WHO Bleeding Assessment Tool (BAT). Women who score more than 6 on th e BAT are referred to our Bleeding Disorders Clinic for further diagnostics and evaluation by a hematologist. During the Bleeding disorders evaluation, the BAT score is repeated and specific testing to define a bleeding disorder is obtained. If patients are identified with a bleeding disorder such as Von Willebrand's disease or congenital platelet disorders, additional therapy to correct these are instituted to improve bleeding. In addition, patients who are severely iron deficient from menorrhagia are offered IV iron replacement.

Results: In the first three months of this project, we have consented and screened over 70 patients in OB/GYN clinic. Twelve patients (17%) that have screened positive with a score of 6 or more. All twelve patients are being evaluated for congenital bleeding disorders. During our project, the Gynecology physicians have become more aware of patients who might be at risk and have increased their self-referral for hematology evaluation. Demographically, most of our patients came from five counties. Each of these counties has a higher rate of uninsured patients with an average of 16.6%, ranging 15-21% compared with national average of 12%. These counties also have higher rates of patient to primary care ratios than national average, minus Pitt County, a training hospital, with a combined average 1,127:1 ranging from 990:1 to 1,270:1 compared to US average 810:1. Median household Income averaged $46,040 ranging $41,200 to $50,300 with US average of $69,700. Black population made up 34.6% on average and ranging from 23% to 56% compared to national average of 12%. And rurality averaged 47.4% ranging 25.4% to 65.6% compared to national average of 19.3%.

Conclusions: This project demonstrates the ability to impact the collaboration between hematology and our gynecology colleagues in identifying undiagnosed bleeding disorders. This study also addresses the disparities faced in medically underserved regions as well as those who have financial and social barriers to care. The rate of positive screening reflects a population of patients who would otherwise not undergo diagnostics at this time potentially missing patients with an untreated bleeding disorder. By better identifying bleeding disorders that complicate gynecologic bleeding, we can develop improved treatment plans to enhance the efficacy of gynecologist control of patient's symptoms. We can also improve the recognition of bleeding disorders by a group of physicians, our OB/Gyn team, who often are the primary providers for many young women in rural Eastern NC.