Cost conscious project:
Microcytic anemia
INTERNAL MEDICINE
BENJAMIN YIP
4/13/16
Background
 Iron deficiency and iron deficiency anemia (IDA) are
common medical problems.
 Iron deficiency affects more than 2 billion people
worldwide.
 IDA is the most common cause of anemia.
 Interpreting iron panels may be challenging.
1. Mclean E et al. Public Health Nutr 2009;12:444-54.
Definitions
 Anemia of chronic disorders or inflammation:
 Multifactorial anemia associated with increased cytokine
production, up-regulation of hepcidin
 Iron deficiency:
 Depressed levels of total body iron, especially iron stores, with
preservation of levels of erythroid iron.
 Iron-deficiency anemia:
 Depressed levels of total body iron in the presence of anemia.
Laboratory tests - Diagnostics
2. Camaschella C. N Engl J Med 2015
Objective/Hypothesis
 To determine if there is appropriate ordering of iron
panels.
 To determine if the internal medicine teams are
appropriately treating microcytic anemia
Methods
 Screening
 Retrospective analysis of all internal medicine patients
hospitalized 4/13/16
 81 patients screened for the presence of iron panel on labs
 Identified 27 patients with recent iron panels.
 Reference range
 Fe: 37-170 mcg/dl
 TIBC: 284-507 mcg/dl
 TSAT: 20-55%
 Ferritin: 10-107 ng/ml
Total Patients
Pt Fe
TIB
C
TSAT Ferr
Hgb
MCV
Tx
Notes
1
41
342
12
79
10.8
80
N
n/a
2
35
232
15
376
7.0
91.2
Y, TID
Prior tx cont
3
105
218
48
146
10.8
97.4
N
ACD +/- GIB
4
129
144
90
4340
6.4
93.0
N
n/a
5
15
405
4
14
8.9
74.3
Y, TID
IDA
6
60
237
25
90
6.8
100.0
N
ACD, HIV from HAART
7
14
326
4
33
9.3
75.7
Y, IV
IDA
8
59
421
14
11
10.6
84.3
N
n/a
9
11
232
5
109
7.5
88.4
Y, IV
ACD vs. IDA
10 58
126
46
2950
7.3
98.5
Y, BID
Reported as ACD, cont
tx since 2014
11
190 223
85
1196
7.0
101.4
N
MDS
12
174
81
2081
6.4
83.0
N
Atypical HUS?
215
Total Patients
Pt
Fe
14
TIBC
TSA
T
Ferr Hgb MCV
Tx
Notes
139 416
33
124
14.2
105.4
N, F/B12
Macrocytosis
15
79
373
21
123
13.3
91.4
N
n/a
16
44
236
19
145
9.1
96.6
N
n/a
17
26
128
20
430
9.6
88.4
N
MDS vs. ACD
18
97
148
66
360
9.5
94.0
N
n/a
19
13
197
7
361
10.5
81.1
N
ACD 2/2 HIV
20
37
256
14
309
7.6
94.6
N
ACD
21
22
311
7
298
8.0
78.1
N
ACD
22
71
150
47
5486 6.3
93.2
N
Chemo pancytopenia
23
35
279
13
297
11.1
91.4
Y, qd
n/a
24
31
235
13
754
10.8
79.7
N
ACD
25
16
243
7
99
7.6
70.1
Y, IV
Possible IDA from GIB
26
59
177
33
111
9.1
89.9
N
ACD
Oral Iron
Pt Fe
TIB
C
TSAT Ferr
Hgb
MCV
Tx
Notes
2
35
232
15
376
7.0
91.2
Y, TID
Prior tx cont
5
15
405
4
14
8.9
74.3
Y, TID
IDA
10 58
126
46
2950
7.3
98.5
Y, BID
Reported as ACD, cont
tx since 2014
23 35
279
13
297
11.1
91.4
Y, qd
n/a
Cost saving – Oral Iron
 Only one patient without anemia – Appropriate
ordering of iron panels.
 12/21/15 – present TID dosing: 114 d x $0.06 =
$6.84
 8/30/11 – present BID dosing: 1688 d x $0.04 =
$67.52
 Unclear initiation – daily dosing: n/a
Intravenous iron
Pt Fe
TIB
C
TSAT Ferr
Hgb
MCV
Tx
Notes
7
14
326
4
33
9.3
75.7
Y, IV x 2
IDA
9
11
232
5
109
7.5
88.4
Y, IV x 2
ACD vs. IDA
13
36
127
28
751
7.2
85.4
Y IV 2 mos
before in ED
Chronic gib, chemo
25 16
243
7
99
7.6
70.1
Y, IV
Possible IDA from GIB
Indications for Parenteral Iron
2. Camaschella C. N Engl J Med 2015
Cost saving – IV Iron
 Iron sucrose (200 mg - $120) compared to ferrous
sulfate 325 mg x 1 - $0.02.
 4 patients with IV iron treatment




2 doses sucrose – IDA. $240
2 doses sucrose – ACD vs. IDA. h/o CAD, HF. $240
4 doses (25 x 2, 1000 x 2) dextran – Severe anemia 2/2 GIB,
panc CA. $606.27
1 dose sucrose – GI loss from rectal CA. AKI Cr 0.6  4.4. $120
Untreated Patients
Pt Fe
TIB
C
TSAT Ferr
Hgb
MCV
Tx
Notes
1
41
342
12
79
10.8
80
N
n/a
3
105
218
48
146
10.8
97.4
N
ACD +/- GIB
4
129
144
90
4340
6.4
93.0
N
n/a
6
60
237
25
90
6.8
100.0
N
ACD, HIV from HAART
8
59
421
14
11
10.6
84.3
N
n/a
11
190 223
85
1196
7.0
101.4
N
MDS
12
174
81
2081
6.4
83.0
N
Atypical HUS?
215
Untreated Patients
Pt
Fe
14
TIBC
TSA
T
Ferr Hgb MCV
Tx
Notes
139 416
33
124
14.2
105.4
N, F/B12
Macrocytosis
15
79
373
21
123
13.3
91.4
N
n/a
16
44
236
19
145
9.1
96.6
N
n/a
17
26
128
20
430
9.6
88.4
N
MDS vs. ACD
18
97
148
66
360
9.5
94.0
N
n/a
19
13
197
7
361
10.5
81.1
N
ACD 2/2 HIV
20
37
256
14
309
7.6
94.6
N
ACD
21
22
311
7
298
8.0
78.1
N
ACD
22
71
150
47
5486 6.3
93.2
N
Chemo pancytopenia
24
31
235
13
754
10.8
79.7
N
ACD
26
59
177
33
111
9.1
89.9
N
ACD
27
107 234
46
861
9.4
98.1
N
n/a
Findings
 Two patients on oral iron unnecessarily for several
years end up spending $74.36 unnecessarily.
 Four patients receiving IV iron cost $1206.27.



Iron dextran: ½ the cost of iron sucrose (risk of
hypersensitivity)
2050 mg elemental iron = 82 days of 325 mg TID (for 25
elemental iron). Compares at $4.92.
However this may be offset by a reduced number of hospital
days/visits or clinic visits.
 Iron deficiency anemia can be difficult to diagnose.
Indications for prior iron should be reviewed on
admission and discontinued if there is no indication.
Conclusions
 7.4% of patients with IDA were not treated
 11.1% of patients with treated with PO ferrous sulfate
unnecessarily.

While the cost is marginal, the patients were taking BID-TID
dosing with a risk of constipation unnecessarily.
 14.8% of patients were treated with IV iron without
an established or even potential indication.

~$1200 increase in cost compared to PO comparison of
elemental iron received.
Bibliography
Mclean E et al. Worldwide prevalence of anaemia, WHO
vitamin and mineral nutrition information system, 1993-2005.
Public Health Nutr 2009;12:444-54.
2. Camaschella C. Iron-Deficiency Anemia. N Engl J Med 2015;
372:1832-43.
1.