1. IDA – Lessons from our local service
Elizabeth Williams - Consultant Gastroenterologist
Poole Hospital NHS Foundation Trust

2. Today’s remit – Our IDA Service at Poole
Why Investigate IDA
How to Confirm IDA
Our service at Poole
Investigation, treatment, prioritization and future developments
Our award winning 2

3. Why investigate IDA?
A common problem : 2-5% of adult men and post-menopausal women have IDA in developed world
1/3 of those investigated will have a GI cause
Overall 10% will have a neoplastic process
IDA should be regarded as an indication for urgent investigation usually with bidirectional endoscopy
A common problem that encroaches on a lot of consultant time in clinics. We are most interested in the 10% that will have a neoplastic process and therefore it is logical that IDA is deemed an indication for…. 3

4. How badly were we doing?– baseline audit 2004
30 patients mean age 71 direct referral to endoscopy with ‘IDA’ no pre-menopausal women
11 had no haematinics
4 normal haematinics
50% may have been investigated inappropriately
Only 25/30 (75%) had bi-directional endoscopy
Only 22/30 (73%) had small bowel biopsy
8/30 (27%) had significant pathology
Firstly we decided to look closely at ouur current state of affairs…how well or how badly were we doing?

5. Time to Investigation 5

6. Where we were Random investigation Not all actually had IDA
Target times not being met
Wasted resource
Nurse led IDA Service –
For asymptomatic patients with IDA
So in conclusion of that small audit we established patients were being investigated randomly. Not all actually had an iron deficiency. Our target times in terms of fast track service were not being met and further more there was a wasted resource surmounting to one endoscopy clinic a week being completely unnecessary. This is of course considerable cost given colonoscopy costs £1000 $2045

7. Objectives of Nurse-Led IDA Service
Improve patient experience
Co-ordinate and rationalise investigations and treatment
Assessment for parenteral iron therapy
Ongoing referral / Follow up of IDA patients
Symptomatic IDA
Refer as usual
Often via the fast-track system.
Improve and streamline the quality of care provide to patients at Poole I play a pivitol role in co-ordinating the service. and to reduce the number of IDA patients undergoing blood transfusion. Bi-directional endoscopy if apropriate is carried out on the same day. CT colon if not apropriate.

8. Confirmation of IDA and referral to IDA Clinic
Classically microcytic but often normal, blood film can help
ferritin – acute phase protein, low sensitivity
Iron/TIBC ratio (transferrin saturation)
IDA - iron /TIBC (trans sat )
ACD - iron / TIBC (trans sat / )
TIBC - pregnancy, OCP
Confirm IDA BEFORE starting supplements
You will notice that peri menopausal females have been included in our cohort which goes against the BSG guidelines on the management of iron deficiency anaemia. Each patient is assessed individually and if there is no good cause for IDA then investigated. We have found 3 women in this cohort with a colorectal cancer. The clinic accelerates the process and is of particular relevance to the 10% of patients with an underlying malignancy.
Eight years after the initial audit we decided to look back at our database and see how well we have been doing.

9. Database Audit 2012
Patients referred by Consultants & GPs between 2004 and 2012
Complete follow-up data available for 720
All patients met criteria for referral :
Sex – 287M : 433F
Median age - 75
IQR years
There were 720 complete data sets available and all patients had been referred by consultants….

10. Database Audit
30.4% were found on investigation to have at least one GI diagnosis considered to be clinically significant
68 (9.4%) had a GI malignancy
Colorectal cancer accounted for 52/68 (76%) of the GI malignancies identified
These statistics are comparable to published data.

12. The majority of patient now are seen and have had their investigation within 28 days. Delays are secondary to patient choice or our choose and book system whereby the patient is given a choice of local hospitals where they might be investigated. The delay occurs in the patient filling out the apropriate forms.

13. Conclusions from Audit
Consistent with the literature, our observations confirm that over 30% of patients with IDA have significant underlying GI pathology
The IDA clinic has radically improved the assessment of patients with suspected IDA, and considerably reduced delays in the patient pathway
Delays to investigation and treatment are now measured in days and weeks rather than weeks and months

14. The IDIOM study Castro-Silva et al 2014
Can we identify those that may not need endoscopy at all?
Can we predict those more at risk of having a GI malignancy?
Can we produce a simple but reliable pre-test predictor of cancer risk?
And therefore perhaps prioritise the order in which the patient has their investigation can we preserve our resources even further.

15. The IDIOM Study Castro-Silva et al 2014
Can clinical parameters predict the likelihood of underlying pathology, in particular, GI malignancy?
Multivariate analysis of our 720 subjects suggests that
Age
Sex
Hb concentration
are strongly associated with the risk of GI malignancy
And this is what we might assume logically.

16. The IDIOM study Castro-Silva et al 2014
Hb quartiles
Q1 : 111 – 158 g/l
Q2 : 102 – 111 g/l
Q3 : 91 – 102 g/l
Q4 : 42 – 91 g/l
We divided our cohort in to hemoglobin quartiles. If you are in quartile 4 and male you are at most risk of haveg a colorectal cancer. If you are female and in quartile 1 most unlikely to have…

17. Results need prospective validation
Our study identified subgroups at very low (<2%) or very high (>20%) risk of GI malignancy
Results need prospective validation
May allow prioritisation of investigation and resources
Low risk patients will still need their anaemia treating and will still require investigation in some circumstances
Family history of GI cancer
Aspirin
Faecal Occult Blood testing
These are only a few of the variables we have looked at. We aim to factor in further studies with additional clinical or laboratory variables Correlation between faecal occult blood testing and iron deficiency.

18. IDA Clinic – Tip of the Iceberg
Patients with IDA transfused
Audit – indications for transfusion in IDA
Retrospective audit March 2008
All patient transfused (>600)
Assessed appropriateness via EPR and notes
30 Patients with IDA transfused
16/30 unnecessary
What I have talked about so far is just the tip of the iceberg. One of the most important changes has been the use of blood in IDA at Poole. Patient was haemodynamically stable not compromised.

19. Cost Implications Cost of blood alone £140.00 per unit $369
Minimum 2 units/ per patient
Minimum £4,500 per month, £54,000 per year $110824!!!!
Clinical Governance issues
Risk management issues
… consider alternatives
Obvious cost implications. Blood is an extremely expensive resoursce and transfusion is not without risk

21. Take Home Messages
If the diagnosis of IDA is suspected it should always be confirmed.
IDA is (usually) an indication for urgent investigation of the GI tract (usually by BDE).
10% of our patients with IDA have an underlying GI malignancy with older, more anaemic men being at highest risk.
The treatment of IDA is iron –oral or iv.
If you want any help setting up such a service I will come to this beautiful country free of charge…call me!!!! 21