Management of Iron Deficiency Anemia in Women of Reproductive Age Using a Telemedicine Platform Fails to Adequately Address Heavy Menstrual Bleeding, Resulting in High Recurrence Rates

Management of iron deficiency anemia (IDA) via telemedicine has become ubiquitous, and has been shown to increase ease of access, and rapidity of administration of IV iron.

Questions persist however about whether forgoing a face-to-face visit results in compromises in the overall care of the patient. Notably, whether the etiology of the IDA is appropriately addressed, and whether appropriate follow up occurs after what is typically a once-off remote encounter.

Since 2020, at our institution, e-Iron has served as a dedicated e-consult platform for the triage and treatment of IDA patients. E-iron makes a simple determination, based on information provided by the referrer, and a cursory chart review, whether IV iron is justified, and expedites the infusion when it is.

Typically, following infusion, no follow up with hematology occurs. Instruction regarding appropriate workup is frequently provided, but this responsibility is deferred to the referring provider, as is follow up after the intervention. Anecdotal observation of multiple repeat referrals raised concern for a high IDA relapse rate after e-Iron.

Noting that 81% of e-Iron referrals are females of reproductive age, our suspicion was that recurrence was attributable to under recognition of heavy menstrual bleeding (HMB) as a cause of IDA, and suboptimal utilization of, and access to, gynecology providers (GYN).

To test this hypothesis, we examined a cohort of non-pregnant women of reproductive age referred to e-Iron over a period of 1 year, with IDA, in whom IV iron was approved.

Of 266 patients analyzed, no documentation of menstrual history, or of HMB, was noted in the encounter from which the referral originated in 25.9% (69). In the referral request, an etiology for the patient’s IDA was specified in 38.3% (102), of which a gynecological factor comprised 90.2% (92), and gastrointestinal factor was proposed in 3.9(4)%, and other etiologies comprising 7.8% (8).

In 15.8% (42) of the cohort, a prior e-iron consult, or referral to hematology for IDA management was noted in the 24 months prior to the index referral.

Recommendations regarding management of IDA were generated in 80.8% (215) of e-Iron responses; either to ‘consider screening for HMB as an etiology for IDA’ (14.4%) or, in cases where a history of HMB was already noted, to ‘address HMB to prevent recurrence of IDA’ (84.2%). Recommendation to screen for GI etiologies in addition to HMB was made in 3 additional patients (1.4%).

In the 3 months after e-Iron, in 36.8% of patients (98) there was no documentation of any effort to screen for or address HMB. In 21.1% (56), a new referral to GYN was placed, but in only 44.6% (31) of these did a GYN encounter occur.

In the 51.8% (117) of patients who were already established GYN patients, an appointment was made in 89.7% (112), but a GYN encounter only occurred in 87.2% (102).

Regarding GYN management, we noted that in 42.1% (112), an investigation was ordered, typically an ultrasound of the uterus, but in 48.2% (58) of these no intervention was thereafter documented. In 29.7% (79), an intervention was documented, notably pharmacological (57%, 45), placement of IUD (12.7%, 10), or surgery (30.4%, 24).

In the 18 month period after e-Iron, anemia recurrence (Hb <11) was documented in 62.3% (142) of patients for whom data was available. In 14.3% (38) no follow up CBC’s were documented after e-Iron.

Recurrences of anemia occurred more frequently in the patients who did not undergo GYN intervention vs. those who did (68.4% vs. 54.3%, p-value 0.05905)

Our data provides evidence that in patients with recognized IDA referred for consideration for IVI via an e-consult platform, there is under recognition of the pathological role of HMB. Following the e-Iron intervention, despite consultants’ exhortation to screen for, and address HMB, this occurs unreliably, likely accounting for a higher than acceptable IDA relapse rate. This may represent a weakness of telemedicine IDA management, and underscores a need to institute modifications of the platform, that preserve the efficacy of the process, without sacrificing holistic management of the underlying problem, expected to occur in a traditional face-to-face hematology encounter.

At our institution, the above has been addressed by the recent introduction to the e-Iron protocol of routine screening for HMB at the time of the iron infusion, and institution of an expedited referral pathway to GYN providers when deemed necessary.