Anemia is a common but under-recognized complication of inflammatory bowel diseases (IBD). Anemia in IBD is associated with increased resource utilization and reduced quality of life. Despite published practice guidelines and quality measures for anemia in IBD, screening for and management of anemia among IBD patients has been poor. To address this gap, the Crohn's and Colitis of America (CCFA) Anemia Care Pathway (ACP) was developed by experts in anemia, IBD, and care pathways, with a screening component comprised of both patient-reported fatigue and laboratory (hemoglobin, ferritin) values. The aim of this study was to test the feasibility of the screening component of the ACP, and to determine the correlation between patient-reported fatigue and anemia.Methods:
The feasibility of anemia screening using the ACP was tested in 5 sites participating in IBD Qorus, a multi-center quality improvement program. Each site received training on use of the Model for Improvement and the ACP at an in-person learning session, followed by monthly teleconferences to discuss barriers to implementing ACP screening. Anemia screening included the self-administered PROMIS fatigue 7a scale, and laboratory tests for hemoglobin and ferritin; a positive screening test was defined by either abnormal fatigue scores or abnormal laboratory values. Anemia was defined by the World Health Organization: hemoglobin <12 g/dL in women, and <13 g/dL in men, and iron deficiency was defined by ferritin values below 30 ng/mL. De-identified data were aggregated across sites for analyses. Outcome measures included proportion of patients who screen positive, completion of screening forms, correlation of PROMIS fatigue scores with anemia, and patient acceptance of participating in screening. Completion rates were reported as percentages of completed screening forms and correlation was assessed using Spearman's rank correlation coefficient.Results:
A total of 460 patients were screened using the PROMIS fatigue scale at 5 sites over a 3-month period, including 180 patients with concurrent hemoglobin, and 73 with both hemoglobin and ferritin laboratory tests. All 7 PROMIS fatigue questions were completed by patients on 95% of forms. Patients reported ease of completing the screening tool (mean 0.5, SD 0.70) on a 0 to 5 Likert scale of difficulty (0 very easy, 5 very difficult). Anemia was identified in 28% of patients with hemoglobin lab tests, and anemia or iron deficiency was found in 38% of those with hemoglobin and/or ferritin tests. PROMIS fatigue scores were weakly correlated with hemoglobin levels (Spearman's Rho = −0.20, P = 0.007), but not presence of anemia. Five of the 7 PROMIS fatigue questions were independently correlated with hemoglobin levels.Conclusions:
In testing the CCFA Anemia care pathway, we identified a high prevalence of anemia among patients with IBD. Patient-reported fatigue is associated with low hemoglobin, and may be able to serve as a screening tool for anemia in patients with IBD.