To Refer or Not to Refer? An Evaluation of Iron Deficiency Anemia Referrals to an NCI-Designated Cancer Center: A Retrospective Review
Authors: Patel Druv Mukesh , Shaker Sarah , Naqvi Amna , Bowhay-Carnes Elizabeth , Karnad Anand 
Published: December 2024

Background: Iron Deficiency Anemia (IDA) is the most common type of anemia and the most common referral to Benign Hematology as identified in a previous study based on the NCI-designated cancer center in San Antonio, Texas. While IDA is often managed by primary care providers, complex or refractory cases of anemia may warrant referral to a hematologist for further evaluation and management. Given the resource constraints of this subspecialty, ensuring that referrals are appropriate and adequately worked up prior to reaching a hematologist is crucial. This study aims to characterize the workup done before, during, and after a new IDA referral to determine the suitability of the referral to the specialty care of a hematologist.
Methods: This retrospective study reviewed new patient referrals for iron deficiency anemia to two benign hematologists practicing in the Mays Cancer Center in San Antonio, Texas over a period of 6 months between November 1, 2023, to April 30, 2024. Data was extracted from the Epic electronic medical record system and entered into the Redcap system, which was then characterized by nature and outcome of referral, pre-referral evaluation, and demographic information.
Results: A total of 83 new referrals for IDA were analyzed over the 6 month period. Of these, 14.5% (n=12) were male and 85.5% (n=71) were female, with a median age of 46 (range: 18-87 years). Forty-four patients (53.7%) were Hispanic and 38 patients (46.3%) were non-Hispanic. The majority of the referrals were from primary care providers (PCP) (77.1%, n=64), while the rest consisted of non-PCP referrals, self-referrals, and referrals from hospitalizations. Interestingly, while 86.7% (n=72) had a prior history of IDA recorded in their chart, 34.9% were found to not have iron deficiency anemia at their initial visit on new patient laboratory studies. The most common etiology of IDA was abnormal uterine bleeding (47.8%, n=33) followed by gastrointestinal pathologies (46.3%, n=21) including malabsorption, bariatric surgery and gastrointestinal blood loss. Notably, IV iron infusions were not recommended in 25.3% (n=21) of patients. Most patients (67.5%, n=56) were recommended oral iron after the initial visit, and within this group, 92.9% agreed to either continue or start taking oral iron. Further management by other specialists after initial hematology visit were recommended in 47.6% (n=34) of new referrals, with 20.7% (n=17) of patients necessitating gastrointestinal referrals and 20.7% (n=17) requiring gynecological referrals. Ultimately, after the initial visit, 33.7% were discharged back to their PCP and did not require further hematology follow-up.
Conclusion: Although IDA remains the most common condition for referral to hematology, a significant proportion did not have true iron deficiency anemia on presentation nor was there a need for iron infusions. We also noted that further workup to identify the etiology of iron deficiency anemia was needed in a proportion of patients. This study demonstrates opportunities for improvement in the referral process, as well as in the management and workup of IDA prior to referral to a hematologist. Better education on the different modalities of oral iron and their respective side effects by primary care providers may improve medication tolerance and compliance, and may limit the future need for hematology consultation or IV iron infusions. Additionally, given the limited availability of hematology appointments, more reliable and efficient methods of consultation, such as e-Consultations, could be made available to assist with IDA referrals to improve resource and time utilization. Additionally, enhanced pre-referral workup by PCPs, including referrals to other specialties related to the etiology of IDA and measuring responsiveness to oral iron therapies, could ensure better appropriateness of these referrals.