EMR dashboard improves pediatric anemia detection, treatment in IBD
AUSTIN, Texas — Incorporating electronic medical record-activated alerts in a pediatric inflammatory bowel disease center improved the detection and treatment of iron deficiency with and without anemia among patients, according to a presenter at the Crohn’s and Colitis Congress.
“Timely diagnosis and management of iron deficiency and anemia in IBD is a challenge in clinical practice. Pediatric pathways are lacking and adult pathways do not address how to best implement in clinical practice,” Jessica Breton, MD, of the Children’s Hospital of Philadelphia, said during her presentation. “Implementation of a pediatric evidence-based care pathway using an EMR-integrated dashboard can improve rates of iron deficiency screening, treatment with iron supplementation and prevalence of anemia”
Breton said that while anemia is a common complication of IBD, developing in 49% to 70% of children and 20% to 39% of adults, it remains under-recognized and under-treated. A year after IBD diagnosis, more than half of patients in remission are still anemic and less than half of those who are anemic are receiving supplementation.
At their institution, Breton and colleagues looked at patients with IBD, starting with a baseline from January to October 2017. At baseline, 35.8% of the nearly 1,600 patients had anemia and 78.7% were screened annually. Only 31.7% were screened for iron deficiency, she said, and overall iron supplementation occurred in just 38.2%.
“While we were doing a relatively good job at screening for anemia, you will appreciate that we were doing poorly at screening for iron deficiency and treating them,” Breton said.
Though the ECCO released a consensus on diagnosis and management of iron deficiency and anemia in IBD in 2015 and IBD Qorus developed an anemia care pathway for IBD in 2017, neither is entirely applicable to pediatrics, she said.
In November 2018, Breton and colleagues launched a quality improvement initiative to improve recognition and treatment of anemia and iron deficiency in children with IBD. Their goal was to reach a 70% threshold for screening of both conditions and at least 70% of patients with iron deficiency or anemia to receive iron supplementation with the development of a pediatric care pathway.
“We know that the creation of a pathway isn’t enough to change physician behavior and induce system wide change, so we implemented a few key strategies,” Breton said.
The pathway, which is available publicly online, was supported through provider education sessions, patient education and incorporating labs into pre-visit planning, Breton said.
“But the most important step was really the creation of an EMR-integrated dashboard that would track our patient and provider performance and that has been really instrumental,” Breton said. “This allowed us to build a monthly provider report and that has been really a game changer to get providers involved in this QI project. I can tell you how useful and time saving this is.”
Providers receive a monthly email detailing all patients flagged as anemic as well whether an iron panel was done and the result of the panel. Additionally, it notes whether iron therapy was initiated and, if so, when the next infusion will be.
In this analysis, researchers measured four metrics: anemia screening, iron deficiency screening among patients with anemia, iron supplementation among patients with anemia and anemia prevalence.
Breton reported that from baseline to November 2019, anemia screening via biannual CBC rose from 72.9% to 79.9%. The iron replacement ordered for patients with anemia increased from 31.7% to 63.6%. Iron supplementation given to patients with anemia rose overall from 38.2% to 49.9% and specifically in patients with quiescent IBD from 26.7% to 42.7%.
“Really, to date, our greatest success has been improving iron deficiency screening,” she said. “We actually doubled our screening rate.”
In the same timeframe, the prevalence of anemia fell overall from 35.8% to 29.7% and in quiescent IBD from 31.2% to 26.4%. The biggest impact came in the prevalence of moderate anemia, which fell from 15.6% to 11.3%. In comparison, mild anemia fell from 18.2% to 17% while severe anemia stayed around 2.2%.
“When we actually stratify patients by disease activity, we did see that we had a slightly greater improvement in patients in clinical remission. That paralleled the decrease in prevalence of anemia,” she said.
Breton noted that the EMR algorithm is sensitive in its identification of patients with mild anemia, there is an underreporting of over-the-counter iron supplementation within the EMR, stratification of patients with iron deficient anemia from those with other types of anemia and there aren’t yet quality of life metrics.
“We are working on modifying our dashboard to specifically capture treatment of iron deficiency anemia and working on integrated patient-related outcomes, including quality of life measures,” she said. “We would like to disseminate and validate the proposed QI initiative in other pediatric IBD centers.” – by Katrina Altersitz
Reference: Breton J, et al. Abstract 27. Presented at: Crohn’s and Colitis Congress; Jan. 23-25, 2020; Austin, Texas.
Breton J, et al. Pathway for Evaluation and Treatment of Iron Deficiency and Anemia in Patients with Inflammatory Bowel Disease (IBD). Website: https://www.chop.edu/clinical-pathway/iron-deficiency-anemia-inflammatory-bowel-disease-ibd-clinical-pathway. Accessed January 28, 2020.
Disclosures: Breton reports no relevant financial disclosures.