The Anemia Workup in Current Clinical Practice: Results From a Survey of Primary Care Physicians

Although the primary care physician (PCP) is often the first provider to diagnose anemia, little is known about the anemia workup in current clinical practice. Knowledge of current practices can inform efforts to improve anemia management in older adults, which has been recognized as a public health crisis by a combined ASH/National Institute of Aging blue ribbon panel. METHODS: From April to August 2010, we administered a 34-item questionnaire to a random sample of 190 Massachusetts physicians identified as PCPs (family practice, general practice, or internal medicine) in the American Medical Association's physician file. PCPs were given a vignette about a hypothetical patient asking “If you were to see a previously healthy patient during a routine physical with mild anemia (Hg 80% of normal) and no other symptoms, which of the following would you do?” PCPs were given 13 choices, but could also write in answers. In the next section, they were told “The patient with mild anemia presents two weeks later. The anemia is unchanged, but the patient has one new sign/symptom in the following list. For each of these as an isolated new finding, what would you do next?” and asked which of 11 signs/symptoms would prompt (1) imaging (2) referral to a hematologist (3) further follow-up. More than one choice was allowed. Results were analyzed descriptively, and significant differences in the second workup stage were identified using Wald chi-square statistics obtained from logistic regression models controlling for correlations of individual PCP responses. RESULTS: 134 PCPs responded (70.5%). 62.4% identified as internists; 58.7% were male. PCPs were evenly distributed with respect to level of academic affiliation. The median reported patient panel size during the prior 12 months was 1800; median percentage of patients ≥ 65 years was 30.0%; median percentage of patients in managed care 55.0%; and median year of graduation from residency, 1996. For the first stage of the workup, most PCPs reported they would send iron studies (93.2%), a differential (85.7%), and B12/folate (85.0%). Fewer would obtain a stool guaiac (69.2%), reticulocyte count (66.2%), or a serum protein electrophoresis (SPEP; 17.3%). At this first stage, 30.8% reported they would require a 2-week follow-up visit, 26.3% a colonoscopy, and 8.3% an EGD. Almost none would refer to a hematologist (3.8%) or obtain imaging (1.5%), and 12.0% wrote in “work-up depends on patient's age.” Reported subsequent actions with persistent anemia and one new sign or symptom were as follows:

Among those patients mostly likely to be referred to a hematologist (those with pancytopenia, thrombocytopenia and leukopenia), PCPs reported recommending low levels of 2-week follow-up in addition to the referral (10.6%, 16.7% and 15.6% respectively). CONCLUSIONS: Use of the reticulocyte count, stool guaiac and SPEP were less frequent than might be expected in the first steps of the anemia work-up; in contrast, more than one-quarter of PCPs reported they would obtain a relatively expensive procedure (colonoscopy) as a first step. Signs and symptoms suggesting bone marrow failure most often prompted referral to a hematologist, while those suggesting lymphoma were generally followed by imaging. Interestingly, an insistent family member could influence hematology referral in the setting of persistent anemia, even more so than night sweats, leukocytosis, or weight loss. These data suggest that several lower-cost diagnostic tools may be underutilized in the PCP's anemia workup, that the workup varies with associated clinical factors, and that patients and families influence the ultimate decision to refer to a hematologist.

No relevant conflicts of interest to declare.