The Value of the Hematologist: Appropriate Use of Diagnostic Endoscopy in Microcytic and Normocytic Anemias (MNA)

Anemia represents a common, significant public health disorder in our society. Anemia is present in 20% of people > 65 years old; microcytic anemias comprise 30% of cases in this age group. In this pilot project, we sought to determine whether the appropriateness of evaluating iron stores, or referral for diagnostic endoscopy, is enhanced when MNA are managed by hematologists-oncologists (HOS) in comparison with other physician specialties (OPS). Methods: The data set examining this question was developed from a single institution (VMMC) as follows: 1) MNA was defined as Hb ≤11 gm/dl and MCV < 100 f L. 2) All MNA between 7/1/2009 and 6/30/2010 were identified from pathology lab records. 3) Pts either a) with previously identified anemia between 1/1/2009 and 6/30/2009, (in an attempt to exclude previously diagnosed MNA per the above definition), or b) males <18 yrs / females <50 yrs (to exclude pediatric cases and female patients with iron (Fe) deficiency due to menstruation and /or pregnancy) were excluded. 4) This pt group was then intersected with a second pt group identified from clinic ICD-9 codes/billing records that had undergone diagnostic upper and /or lower endoscopy during the same time period to create the final data set. 5) Evaluation of Fe stores in this population was determined. 6) Endoscopy referral was considered appropriate if either a) a diagnosis of Fe deficiency was suggested from Fe studies (i.e. Fe saturation <15% or ferritin <25 mcg/dl) or b) an alternative non-hematologic indication (e.g. abdominal pain) was adequately reported in the endoscopy record; endoscopic referral was otherwise considered inappropriate. 7) Management responsibility was assigned to HOS if pts were seen by this subspecialty within 30 days of MNA identification. 8) Statistical significance was analyzed using the Chi-squared test statistic unless otherwise specified. Results: Using this method,1,908 pts with MNA were identified; of these 496 (26%) also underwent diagnostic endoscopy. 140 patients (28%) were managed by HOS; 356 (72%) by OPS Patients managed by HOS and OPS providers differed respectively for frequency of male sex (82/140 pts, 59% vs.146/356 pts 41%), percentage microcytic vs. normocytic anemia (92/356 pts, 28% vs.17/140 pts, 12%) and frequency of Fe deficiency (143/355 pts, 40%), vs. 21/140 pts 15%, all p<0.001). Most pts with microcytic anemias who underwent endoscopy had Fe studies performed regardless of managing physician specialty (HOS 12/17 pts, 71% vs. OPS 76/92 pts, 83%, p=NS). Patients with hematologic indications for endoscopy (Fe deficiency or anemia) were less likely to be managed by HOS than by OPS (23/140 pts, 16%, vs. 167/356 pts, 47%, p< 0.001). However, the overall rate of endoscopic appropriateness per the above criteria was statistically higher for HOS, both overall (138/140 pts, 99%, vs. 333/356 pts 94%, p=0.02, Fishers exact test) and excluding pts undergoing endoscopy with Fe deficiency (117/119 pts, 98%, vs. 190/213 pts, 89%, p<0.001). Multivariate logistic regression analysis revealed the odds of inappropriate endoscopy was 6.2 times higher (95% CI 1.5–55.4) in pts managed by OPS than HOS. This probability is similar when comparing the subset of OPS who are primary care providers (172/187 pts of OPS, 92%, odds ratio 11.2, 95% CI 2.4–107, p<0.001) Conclusions: In this experience, 1) diagnostic endoscopy performed in association with MNA was a common occurrence. 2) Pts with MNA referred for diagnostic endoscopy were more likely to be managed by OPS than HOS; their pt populations differed in frequency of male sex, MCV, and Fe deficiency. 3) In microcytic anemia, Fe studies were used similarly by HOS and OPS. 4) Endoscopic evaluation of MNA is more likely to be appropriate when managed by HOS than OPS. 5) This approach to assess case management appropriateness could be extended to larger populations, including claims-based data sets. This abstract was submitted on behalf of the ASH Committee on Practice Quality Subcommittee.

No relevant conflicts of interest to declare.