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. 2002 Sep;78(923):533–537. doi: 10.1136/pmj.78.923.533

Investigation and management of iron deficiency anaemia in general practice: a cluster randomised controlled trial of a simple management prompt

E Logan 1, J Yates 1, R Stewart 1, K Fielding 1, D Kendrick 1
PMCID: PMC1742500  PMID: 12357013

Abstract

Background: Iron deficiency anaemia (IDA) remains the most common cause of anaemia and is frequently secondary to occult gastrointestinal blood loss requiring further investigation. The study was designed to prospectively assess the adequacy of investigation of IDA and to establish whether a simple computerised prompt would increase the completeness of investigation of patients presenting to their general practitioners.

Patients and methods: All men aged >20 and women aged >50 newly found to have a probable IDA (n=431) in primary care were randomised according to general practice (n=89) to one of two computer generated prompts, by the haematology laboratories in two large district general hospitals. Data were collected 12 months after the index date. The primary outcome measure was the adequacy of investigation of the cause of anaemia. Multiple logistic regression was used to analyse each binary outcome.

Results: Two hundred and three (47%) of 431 patients presenting to their general practitioner with an IDA were adequately managed and 140/357 (39%) of patients who were otherwise fit for investigation had no tests at all. Twenty one (17%) of 125 patients who did have adequate investigation at the time of presentation were found to have colorectal cancer. Only 30% of patients had a confirmed diagnosis within 12 months.

The prompt did not affect the level of investigation (odds ratio 0.88, 95% confidence interval (CI) 0.60 to 1.29, p=0.52). The initial prescribing of oral iron was improved (odds ratio 2.19, 95% CI 1.27 to 3.77, p=0.005), but not the documented prescribing of a full therapeutic course or the use of follow up blood counts.

Conclusions: The investigation and management of IDA presenting in general practice remains inadequate and is not improved by a simple management prompt.

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Selected References

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  1. Beardon P. H., McGilchrist M. M., McKendrick A. D., McDevitt D. G., MacDonald T. M. Primary non-compliance with prescribed medication in primary care. BMJ. 1993 Oct 2;307(6908):846–848. doi: 10.1136/bmj.307.6908.846. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Cook I. J., Pavli P., Riley J. W., Goulston K. J., Dent O. F. Gastrointestinal investigation of iron deficiency anaemia. Br Med J (Clin Res Ed) 1986 May 24;292(6532):1380–1382. doi: 10.1136/bmj.292.6532.1380. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Donner A., Birkett N., Buck C. Randomization by cluster. Sample size requirements and analysis. Am J Epidemiol. 1981 Dec;114(6):906–914. doi: 10.1093/oxfordjournals.aje.a113261. [DOI] [PubMed] [Google Scholar]
  4. Eccles M., Steen N., Grimshaw J., Thomas L., McNamee P., Soutter J., Wilsdon J., Matowe L., Needham G., Gilbert F. Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial. Lancet. 2001 May 5;357(9266):1406–1409. doi: 10.1016/S0140-6736(00)04564-5. [DOI] [PubMed] [Google Scholar]
  5. FRY J. Clinical patterns and course of anaemias in general practice. Br Med J. 1961 Dec 30;2(5269):1732–1736. doi: 10.1136/bmj.2.5269.1732. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Frewin R., Henson A., Provan D. ABC of clinical haematology. Iron deficiency anaemia. BMJ. 1997 Feb 1;314(7077):360–363. doi: 10.1136/bmj.314.7077.360. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Grimshaw J. M., Russell I. T. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993 Nov 27;342(8883):1317–1322. doi: 10.1016/0140-6736(93)92244-n. [DOI] [PubMed] [Google Scholar]
  8. Hibble A., Kanka D., Pencheon D., Pooles F. Guidelines in general practice: the new Tower of Babel? BMJ. 1998 Sep 26;317(7162):862–863. doi: 10.1136/bmj.317.7162.862. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Hin H., Bird G., Fisher P., Mahy N., Jewell D. Coeliac disease in primary care: case finding study. BMJ. 1999 Jan 16;318(7177):164–167. doi: 10.1136/bmj.318.7177.164. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Joosten E., Ghesquiere B., Linthoudt H., Krekelberghs F., Dejaeger E., Boonen S., Flamaing J., Pelemans W., Hiele M., Gevers A. M. Upper and lower gastrointestinal evaluation of elderly inpatients who are iron deficient. Am J Med. 1999 Jul;107(1):24–29. doi: 10.1016/s0002-9343(99)00162-x. [DOI] [PubMed] [Google Scholar]
  11. Langley C., Faulkner A., Watkins C., Gray S., Harvey I. Use of guidelines in primary care--practitioners' perspectives. Fam Pract. 1998 Apr;15(2):105–111. doi: 10.1093/fampra/15.2.105. [DOI] [PubMed] [Google Scholar]
  12. Lucas C. A., Logan E. C., Logan R. F. Audit of the investigation and outcome of iron-deficiency anaemia in one health district. J R Coll Physicians Lond. 1996 Jan-Feb;30(1):33–36. [PMC free article] [PubMed] [Google Scholar]
  13. McIntyre A. S., Long R. G. Prospective survey of investigations in outpatients referred with iron deficiency anaemia. Gut. 1993 Aug;34(8):1102–1107. doi: 10.1136/gut.34.8.1102. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Rockey D. C., Cello J. P. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N Engl J Med. 1993 Dec 2;329(23):1691–1695. doi: 10.1056/NEJM199312023292303. [DOI] [PubMed] [Google Scholar]
  15. Siriwardena A. N. Clinical guidelines in primary care: a survey of general practitioners' attitudes and behaviour. Br J Gen Pract. 1995 Dec;45(401):643–647. [PMC free article] [PubMed] [Google Scholar]
  16. Stellon A. J., Kenwright S. E. Iron deficiency anaemia in general practice: presentations and investigations. Br J Clin Pract. 1997 Mar;51(2):78–80. [PubMed] [Google Scholar]
  17. Thompson C., Kinmonth A. L., Stevens L., Peveler R. C., Stevens A., Ostler K. J., Pickering R. M., Baker N. G., Henson A., Preece J. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet. 2000 Jan 15;355(9199):185–191. doi: 10.1016/s0140-6736(99)03171-2. [DOI] [PubMed] [Google Scholar]
  18. Till S. H., Grundman M. J. Prevalence of concomitant disease in patients with iron deficiency anaemia. BMJ. 1997 Jan 18;314(7075):206–208. doi: 10.1136/bmj.314.7075.206. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Unsworth D. J., Lock R. J., Harvey R. F. Improving the diagnosis of coeliac disease in anaemic women. Br J Haematol. 2000 Dec;111(3):898–901. [PubMed] [Google Scholar]
  20. Waller D. G., Smith A. G. Attitudes to prescribing iron supplements in general practice. Br Med J (Clin Res Ed) 1987 Jan 10;294(6564):94–96. doi: 10.1136/bmj.294.6564.94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Watkins C., Harvey I., Langley C., Gray S., Faulkner A. General practitioners' use of guidelines in the consultation and their attitudes to them. Br J Gen Pract. 1999 Jan;49(438):11–15. [PMC free article] [PubMed] [Google Scholar]
  22. Wensing M., van der Weijden T., Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract. 1998 Feb;48(427):991–997. [PMC free article] [PubMed] [Google Scholar]
  23. Wilcox C. M., Alexander L. N., Clark W. S. Prospective evaluation of the gastrointestinal tract in patients with iron deficiency and no systemic or gastrointestinal symptoms or signs. Am J Med. 1997 Nov;103(5):405–409. doi: 10.1016/s0002-9343(97)00168-x. [DOI] [PubMed] [Google Scholar]
  24. Willoughby J. M., Laitner S. M. Audit of the investigation of iron deficiency anaemia in a district general hospital, with sample guidelines for future practice. Postgrad Med J. 2000 Apr;76(894):218–222. doi: 10.1136/pmj.76.894.218. [DOI] [PMC free article] [PubMed] [Google Scholar]

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