Overcoming the Obstacles That Prevent Identification and Treatment of Women Who Have Iron Deficiency

Background: ­Iron deficiency (ID) is the most common nutritional deficiency in pregnancy, in women who have menstrual periods, and among people who have had bariatric surgery. In pregnant women, iron deficiency anemia (IDA) has been associated with maternal morbidity, peripartum complications, and impaired infant development. Among all populations with IDA, common symptoms include severe fatigue, shortness of breath, and impaired concentration, with consequences including diminished work productivity and reduced quality of life. Because women have ID more frequently than men do, ID may be viewed as a driver of gender inequality.

It has been a challenge to identify and treat women who have ID. The barriers to identifying these women have included (1) lack of awareness about low iron among women and their physicians, (2) lack of understanding about the difference between hemoglobin testing and iron testing, (3) inability of women to get tested without a lab test order from their physician, (4) variation in interpretation of iron saturation and ferritin test results among providers, and (5) variation in interpretability of iron saturation and ferritin tests in different patient populations.

The obstacles that prevent treatment of ID with iron infusions have included (1) lack of understanding about limited efficacy and tolerability of oral iron supplements, (2) lack of awareness about the safety, efficacy, and tolerability of iron infusions, (3) lack of patient access to infusion clinics that are capable of doing iron infusions promptly and safely, (4) lack of physician comfort writing iron infusion orders, and (5) variation in health plan coverage of iron infusion costs.

Methods: We developed a system to overcome the barriers to identifying women who have ID and the obstacles that prevent women from receiving iron infusions. Our system included education of women's health physician practices, delivered by a clinician-led education team, as well as print and social media advertisements. Patients who were referred to our practice were promptly evaluated online in telemedicine hematology consults provided by one hematologist physician and a well-trained team of advanced practice providers (APP's). This enabled consistent interpretation of patients' symptoms and lab test results, as well as thorough explanations about ID and iron infusions.

To overcome the obstacle of health plan coverage, we created a team of well-trained iron infusion coordinators to promptly obtain health plan authorization and troubleshoot lack of coverage. To do the infusions, we created a network of dedicated iron infusion centers with well-trained nurses and supervising APP's. We established protocols to address infusion reactions, and workflows to enable several women to safely receive iron infusions at the same time.

Results: 6,101 patients were evaluated online in hematology telemedicine consults between June 2020 and June 2023, with a 5-10% month-to-month increase in referrals. Of these patients, 3,076 patients who had iron deficiency received a total of 7,246 iron infusions over two years. 1,383 (45%) of these were pregnant women. The iron formulations infused were partly determined by the patient's health plan coverage. These included Ferric Derisomaltose (1,055 infusions), Ferumoxytol (1,481 infusions), Iron Sucrose 200 mg doses (n=3,962 infusions), Iron Sucrose 400 mg doses (n=723 infusions), and Ferric Carboxymaltose (20 infusions).

Our system enabled prompt patient evaluations because of the flexibility of doing telemedicine patient visits. Some patients were seen online the day after they were referred. The average time from a televisit to an iron infusion was nine days, with some patients receiving iron infusions the day after their televisit. Our retrospective chart review demonstrated that 94% of patients who received iron infusions reported improvement of one or more ID-related symptoms (shortness of breath, fatigue, or ice craving/ice chewing). The overall incidence of adverse reactions occurring during infusions was 4.5%, with some variation among the iron formulations.

Conclusions: Our hematology practice has overcome barriers to identifying women who have iron deficiency, and obstacles that prevent treatment with iron infusions. The solution to this problem involves educating women and women's health providers, and creating a system to plan and perform iron infusions promptly and safely.