Original ContributionsFactors Associated with Hospitalization among Emergency Department Patients Referred for Quick Investigation of Iron-Deficiency Anemia
Introduction
Patients with anemia are frequently seen in emergency departments (EDs), and emergency physicians may play an essential role in their evaluation and initial management (1). However, data on the frequency of anemia in the general ED population are limited (2). Notably, apart from reports on the occurrence and management of anemia in pediatric, obstetric, and gynecologic (i.e., abnormal uterine bleeding) patients, ED patients with sickle cell disease, and ED management, including red blood cell (RBC) transfusion strategies in patients with acute gastrointestinal (GI) hemorrhage or in trauma and critical care, no studies on adult subjects presenting to EDs with symptomatic chronic anemia—most commonly corresponding to microcytic, iron-deficiency anemia (IDA) caused by occult GI bleeding—have been reported 1, 2, 3.
In Spain, a country with a publicly funded health system, physicians at primary care centers (PCCs) commonly refer patients with moderate to severe IDA (hemoglobin <10 g/dL) to EDs to gain quicker access to GI investigations via emergency admission 4, 5. While the standard operating procedure has been to hospitalize these patients, even the young ones, for speeding diagnostic workup, the recent creation of hospital-based outpatient quick diagnosis units (QDUs) has represented a shift in PCC referrals and ED admission practices (4). In patients with different potentially serious conditions, frequently associated with cancer, QDUs have proven a solution to diagnostic delays and an efficient, cost-saving alternative to hospitalization for diagnostic workup 4, 5, 6, 7, 8. While referral criteria for anemia vary among QDUs, our unit assesses anemic patients, mostly with new, uninvestigated IDA, with an index hemoglobin value measured at the time of presentation to the ED (“baseline hemoglobin”) of <9 g/dL and no acute GI bleeding. Although the optimal hemoglobin threshold warranting quick investigation of IDA has not been elucidated, the rationale for using this cutoff is evidence showing that risk of GI (mainly colorectal) malignancy in IDA patients is significantly increased when the hemoglobin level is <9 g/dL 9, 10, 11, 12. Initial observations showed, however, that some patients with IDA presenting to the ED with baseline hemoglobin <9 g/dL who were referred to QDU were unpredictably hospitalized shortly after starting the QDU assessment.
The delineation of risk factors has permitted us to systematize the care, including the appropriate management setting (inpatient vs. outpatient setting) of patients presenting with acute overt GI hemorrhage and secondary anemia, and improved decision-making at the early triage level has led to improved outcomes, resource use, and overall management (13). In contrast, factors associated with hospitalization of patients presenting to EDs with significant chronic IDA are unknown, meaning that early care and triage to the proper level of care for evaluating these patients for diagnostic purposes relies primarily on the judgment of referring physicians or on institution practices or guidelines.
To elucidate this evidence gap, the goal of this study was to determine, among ED adults referred to the QDU of a third-level university hospital for investigation of IDA, the patient factors associated with hospitalization after the initial QDU visit.
Section snippets
Study Design
This was a prospective cohort study of patients with IDA who were consecutively referred from the ED to the QDU between September 2005 and October 2013. The primary outcome was hospitalization after initial QDU consultation. The research ethics committee of the hospital approved the study, and informed consent was obtained from all patients.
Study Setting and Population
The QDU is located in an 870-bed third-level university hospital in Barcelona (Spain) with a reference population of almost 550,000. The main requirements
Results
Among 3814 initially eligible patients referred to the QDU who had proven IDA, 53 had patent blood losses from non-GI sources (e.g., profound menstruation in 33 premenopausal and metrorrhagia in 15 postmenopausal women), 38 were lost to follow-up, 17 refused to participate, and 14 died before outpatient investigations concluded. Analysis was restricted to 3692 patients, with a mean age of 65.2 (17.4) years, and 1911 (52%) patients were women. Some enrolled patients (2 hospitalized and 114
Discussion
This prospective study is, as far as we are aware, the first to examine the patient factors associated with admission among adults referred from the ED for prompt outpatient investigation of IDA. In our study, 7.7% of subjects with confirmed IDA with baseline hemoglobin levels in the ED of <9 g/dL were hospitalized after onward referral to and initial assessment at an outpatient diagnostic clinic that is expressly devised to rapidly investigate patients with potentially serious diseases.
Conclusions
Various patient factors were independently associated with admission among ED patients who were referred for rapid outpatient investigation of IDA. These predictive factors are easily available on the initial ED evaluation and can guide the triage to the most appropriate and safe setting for timely investigation. Although these independent predictors do not necessarily portray the need for admission, their knowledge may be useful for emergency physicians who encounter similar patients with IDA
References (33)
- et al.
Anemia
Emerg Med Clin North Am
(2014) - et al.
AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding
Gastroenterology
(2000) - et al.
Quick diagnosis units or conventional hospitalisation for the diagnostic evaluation of severe anaemia: a paradigm shift in public health systems?
Eur J Intern Med
(2012) - et al.
Quick diagnosis units-an effective alternative to hospitalization for diagnostic workup: a systematic review
J Hosp Med
(2014) - et al.
Prediction of outcome of acute GI hemorrhage: a review of risk scores and predictive models
Gastrointest Endosc
(2004) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987) - et al.
Validation of a combined comorbidity index
J Clin Epidemiol
(1994) - et al.
Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment
J Clin Epidemiol
(1998) - et al.
The prevention of transfusion associated circulatory overload
Transfus Med Rev
(2013) - et al.
A novel approach to identifying targets for cost reduction in the emergency department
Ann Emerg Med
(2013)
Anemia in the emergency department: evaluation and treatment
Emerg Med Pract
Should alternatives to conventional hospitalisation be promoted in an era of financial constraint?
Eur J Clin Invest
Quick diagnosis units: a potentially useful alternative to conventional hospitalization
Med J Aust
Evaluation of unexplained peripheral lymphadenopathy and suspected malignancy using a distinct quick diagnostic delivery model: prospective study of 372 patients
Medicine (Baltimore)
The importance of anaemia in diagnosing colorectal cancer: a case-control study using electronic primary care records
Br J Cancer
Risk factors for gastrointestinal malignancy in patients with iron-deficiency anaemia
Eur J Gastroenterol Hepatol
Cited by (5)
Open questions and misconceptions in the diagnosis and management of anemia in patients with gastrointestinal bleeding
2018, Gastroenterologia y HepatologiaA comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9 mg/dL: A prospective cohort study
2017, Digestive and Liver DiseaseCitation Excerpt :Providing that physical performance is well enough to travel to hospital for tests and visits, patients with unexplored anemia (almost always corresponding to microcytic anemia with suspected iron deficiency) with hemoglobin values <9 g/dL are currently referred from the emergency departments (EDs) and primary care centers (PCCs) to our hospital for prompt evaluation by QDU physicians [22,23]. Previous studies have shown that in comparison with most IDA patients uneventfully assessed at QDUs following ED referral, other patients are more likely to be hospitalized soon after the first QDU visit, before conducting GI procedures, due to clinically symptomatic anemia, high fatigue, and comorbidities (mainly cardiovascular disease) associated with significantly lower hemoglobin values [24]. To determine whether the underlying causes of IDA could explain these different outcomes, we undertook a prospective study to investigate GI disorders accounting for IDA in a large cohort of patients referred to QDUs with baseline hemoglobin values <9 g/dL, iron deficiency, and no extraintestinal causes of blood loss or iron deficiency.
Management of nutritional iron deficiency anemia for young children in the emergency department
2023, Pediatric Blood and Cancer
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