An Analysis of e-Iron: Updates from a Year of Experience with a Novel IV Iron Telemedicine Platform

Introduction: Intravenous iron (IVI) is increasingly being recognized as a safe and effective strategy in addressing the needs of patients with iron deficiency anemia (IDA) who fail to respond to oral iron, or are unable to tolerate it. However, convoluted referral processes frequently act as a barrier between referring providers and the infusion facility, resulting in significant underutilization of IVI.

Capitalizing on a robust e-consult platform operational at our institution, e-IRON was built as a function in the EPIC EMR, to facilitate 'electronic’ referral for consideration for IVI, and in this way simplify and expedite the process of IVI referral.

Using a template-based design, the e-IRON order 'gathers’ key information (indication, experience with oral iron, current lab-work), which, together with a 'chart-review', are evaluated by a specialist hematologist within 3 days. If IVI is deemed appropriate, this is scheduled directly. If a face-to-face hematology appointment is required, this is similarly scheduled. Where IVI is not deemed appropriate, guidance as to alternate management is provided.

We previously demonstrated in a small cohort that e-IRON expedites hematologist assessment of patients’ candidacy for IVI, and significantly shortens the time from referral to infusion scheduling. Similarly, we demonstrated that only a small fraction of patients required in-person appointments. We now share our experience with a larger cohort, adding outcomes data, with an analysis of patient parameters observed in the year subsequent to e-IRON referral.

Results: Over 1 year, 477 unique consults were placed. The overall rate of IVI approval was 65%, with similar results for each indication. The most common reason for denial (10.3%) was failure to document a failed trial of oral iron. In 8.4% IVI was denied because required information, typically current labwork, was not provided.

Detailed chart review was performed on a sub-cohort of 119 (25%) patients, focusing on post e-IRON outcomes in an evaluation period of 1 year after the initial consult. In 76 patients (64%) IVI was approved, and of these 67 (88%) received at least their first dose, occurring a median of 12 days after the e-IRON consult was placed.

In patients approved for IVI, and who received infusion, an average increase of 2.48 g/dL ((95% CI 2.48 - 3.20) was observed. Regardless of indication and intervention, patients had an average increase in Hb of 2.03 g/dL (95%CI 1.69-2.38) from their pre-consult value to their first post-consult value.

All scheduled regimens comprised 1 or 2 infusions, using either iron dextran, or ferric carboxymaltose. The average dose was 1200 mgs, ranging from 750 to 2000 mgs.

No adverse reactions to IVI were reported in this cohort.

Of 15 patients in whom a trial of oral iron was recommended, 8 responded satisfactorily, 2 'failed’ their trial and subsequently received IVI, and in 5 follow-up was incomplete.

Eight patients required blood transfusion during the evaluation period, most commonly in the context of peri-partum hemorrhage.

In 19 patients, repeat e-IRON consults were placed during the evaluation period, and in 13 of these IVI was approved and administered, typically after information missing from the initial consult was provided.

Follow up regarding patients’ anemia by the referring provider within 4 months of e-IRON occurred in 37 of 43 (86%) patients in whom IVI was not approved, and 63 of 76 (82%) in whom it was.

Conclusions: Since the hematologist's involvement with the vast majority of e-IRON patients is limited to a brief chart review, concern had been expressed that this 'hands-off’ approach might result in suboptimal subsequent management and follow up. However this was not borne out in this outcome analysis, wherein we saw high rates of infusion completion in scheduled patients, and compliance with e-IRON recommendations on the part of referring providers.

Our continued experience with e-iron verifies the feasibility and efficiency of a telemedicine approach in expediting the management of patients requiring IVI. In the vast majority of cases e-IRON enables unprecedentedly rapid determination of management and facilitation of IVI when appropriate, dispensing with the costly and time consuming traditional requirement of a face-to-face visit to the hematology clinic. The resultant benefits to patients, their primary care providers, and to over-burdened specialty providers are self-evident.

Chaitowitz:Pharmacosmos: Consultancy, Honoraria.