Proactive Management of Iron Deficiency and Anemia in Pediatric Inflammatory Bowel Disease—Development of a New Care Pathway

Abstract

Anemia is a common complication of inflammatory bowel disease (IBD), with studies reporting an even greater prevalence among children (49-70%) than adults (20-39%) at any given time during disease course. In the majority of cases, anemia is a result of iron deficiency (ID), chronic inflammation, or a combination of both. Both anemia and ID itself have been associated with high rates of IBD-related complications, resource utilization, and impaired quality of life. However, ID and anemia remain under-recognized and undertreated. To align clinical practice with guideline recommendations, we developed a clinical care pathway for screening, management, and follow-up of ID and anemia among pediatric patients with IBD. In the absence of specific pediatric guidance, these recommendations are based on international adult clinical guidelines and evidence-based pediatric publications. We aim to achieve a 70% screening and intervention rate by June 2019. This QI initiative was started at the CHOP IBD Center in November 2017. PDSA cycles included review of our current performance with all IBD providers (11/2017), educational sessions given in the inpatient and outpatient setting (01/2018), modification of the divisional IV iron therapy order set (02/2018), development of a new clinical pathway for active screening and management of iron deficiency and anemia (1st version available 2/2018 and open access online 11/2018), and creation of individualized monthly reports for all of our GI providers identifying patients with anemia (12/2018). In parallel, ferric carboxymaltose was made available for outpatient management of iron deficiency as of November 2017. Baseline data from July 2016 was compared to data after initiation of the QI initiative. Prior to this QI initiative, review of our performance at CHOP, revealed that 35.7% of our active outpatient IBD population was anemic, however only a minority of these patients were being screened for iron deficiency (20%) and appropriately treated with supplementation (18.4%). Following the implementation of this QI project, improvement was observed with screening and treatment rate increasing to 54.6% and 36.9% respectively by February 2019 (Figures 1 and 2). Iron deficiency and anemia is commonly underdiagnosed and undertreated in children with IBD. An evidence and expert based pathway may help increase screening and intervention. We expect to show continued improvement once this pathway is fully incorporated into clinical practice.