Evaluating Trainees' Experiences with Intravenous Iron Use
Authors: Feder Katherine J , Firn Janice I. , Van Doren Layla N 
Published: December 2023

Background: Iron deficiency (ID) and iron deficiency anemia (IDA) cause significant morbidity. Despite being a disease of high prevalence, affecting people with heart failure, chronic kidney disease, heavy menstrual bleeding, irritable bowel disease, hereditary hemorrhagic telangiectasia (HHT), and bariatric surgery, it has low healthcare priority. The World Health Organization (WHO) estimates 37% of people who are pregnant, and 30% of women 15-49 years of age worldwide are anemic. Fibroids, which are the leading cause of abnormal uterine bleeding, disproportionately impact people of color. ID and IDA cause fatigue, impaired cognitive function, and poor mental health, eroding quality of life and personal productivity. In addition, IDA has been associated with an increase in all-cause mortality is associated with an increased risk of arterial and venous thrombosis. Under-treatment of IDA results in avoidable hospitalizations, emergency room visits, blood transfusions, decreased HRQoL, and loss of personal productivity. Despite the significant impact ID and IDA can have on morbidity, mortality, and quality of life, intravenous iron remains underutilized. No study has been performed to date to assess provider practices, knowledge, and perceptions of intravenous iron use. This qualitative study aims to understand trainees' experiences with intravenous iron use in patients with ID and IDA.

Methods: We conducted an inductive reflective thematic analysis of semi-structured qualitative interviews from five focus groups to understand trainees' experiences with and barriers to prescribing intravenous iron in patients with ID and IDA. Internal medicine residents from academic institutions across the country were recruited via snowball sampling. Chief residents from six internal medicine programs were contacted to disseminate sign up links to their residents; programs were chosen for geographic diversity.

Results: Twenty-eight internal medicine residents responded and nineteen residents across five institutions participated (PGY levels 1-3). Thematic analysis of trainees' experiences of caring for patients with conditions characterized by iron deficiency resulted in three main themes: education, systemic factors, and practice pattern. Participants identified a wide range of conditions for which they consider administration of oral or intravenous iron. However, they generally expressed uncertainty as to whether evidence-based guidelines exist to guide their decision-making with the exception of intravenous iron administration in heart failure patients. In addition, systemic factors, such as setting, support staff, hospital formularies, order sets, and insurance status often impacted their decision to use intravenous iron.

Conclusions: There is a wide variation among residents' practice patterns in regard to their comfort with prescribing intravenous iron. The ease or hesitancy with which they do so is greatly influenced by educational and systemic factors. By gaining a deeper understanding of the experiences of trainees we can lay the foundation to develop evidence-based guidelines and educational initiatives for conditions characterized by ID and IDA. Additionally, by identifying both institutional facilitators and barriers, we can cultivate system-based initiatives to improve access to intravenous iron. To assess this need on a larger scale, our next step involves developing a survey that will be widely distributed via national societies. While cost, insurance status, and need for specialty referral were identified as barriers for intravenous iron use, there was no explicit discussion of how these barriers may contribute to healthcare inequity for underserved populations.