Clinical

Diagnosis

Anaemia

Background

  • Anaemia clinically describes a haemoglobin value below the lower limit of the normal range.
  • There are a wide variety of causes which range from part of the normal ageing process to serious life threatening disease, including stomach or bowel cancer and leukaemia or aplastic anaemia
  • The high prevalence of mild anaemia in the older population may account for widespread unnecessary over-investigation of patients. In younger patients the challenge of establishing the cause of anaemia and most appropriate management and /or need for referral are not sufficiently recognised.

Patient View

  • Anaemia is usually not recognised by patients who only become aware of the issue following a blood test, which often leads patients to mistake anaemia as the cause of their symptoms (rarely the case, because normal human physiology readily adapts to mild anaemia). Likewise, longstanding GI symptoms but recent anaemia, can trigger referral to hospital, often via the TWW pathway causing unnecessary patient anxiety.

Current Practice

  • The key to clinical management is in correctly identifying the cause of the anaemia (inadequate components to make haemoglobin, problems with bone marrow and excess loss, either from menstruation or GI blood loss).

Opportunities for Integrated Working

  • Several groups have already demonstrated benefits arising from integrated pathways to assist identifying cause of anaemia and subsequent most appropriate managements.
  • Considerable if appropriate integrated working between primary and secondary care (involving haematology, gastroenterology, geriatrics and gynaecology).

Opportunities for Savings

  • Iron Deficiency Anaemia is a common reason for referral, but for which referral pathways and processes are often ill defined leading to duplication or inappropriate management.
  • Patients should only be referred to a gastroenterologist if they have iron, B12 or folate, deficiency not explained by menorrhagia should achieve a modest reduction in similarly inappropriate referral and endoscopic investigation.

Quality Indicators / Outcome Measures

  • Evidence of interface clinical assessment service for anaemia
  • Proportion of patients with established IDA being appropriately investigated with ‘one stop’ gastroscopy and colonoscopy.
  • Proportion of patients having repeat investigations due to oral iron therapy being stopped

Social Policy & Understanding

  • The widespread and increasing use of anti-platelet drugs (aspirin and clopidogrel) and anti-coagulants (warfarin and newer agents) will inevitably lead to an increase in the number of patients with IDA from GI blood loss.

References