1. Addressing Iron Deficiency Anemia 181st Street Clinic (Washington Heights Family Health Center) 2006-7 PDSA Project

2. Why Tackle Iron Deficiency? • #1 Nutritional Disorder in World • 80% Fe Deficient • 30% some form of Fe Deficient Anemia • Easily Administered Therapy

3. SUPPLEMENTATION WORKS! • Effect on of treatment • .78 mg/dL difference in those treated • Positive Effects on Developmental Outcomes • Cognition?

4. AIM Statement Reduce the impact of iron deficiency and iron deficiency anemia in children under 3 in our practice by: • Increasing the identification of children at risk • Implementing evidence-based treatment of iron deficiency anemia • Establishing primary prevention of iron deficiency for an at-risk population (Patients aged 1-3 years)

5. PDSA for Prevention of Anemia P: Implement primary prevention of iron deficiency D: Providers began prescribing prophylactic MVI with iron to all patients aged 1-3 years S: Chart Review (2 wks post intervention): • Providers prescribing prophylactic MVI with Iron to 81% of patients 1-3 years A: Expanded education efforts to ALL providers including nurse practitioners

6. AAP Iron-deficiency Screening and Treatment Guidelines • Universal Screening in high risk communities • Hgb or Hct between 9-12 months, and again 6 months later • Treatment • Treat pts 6m-1.9y with Hb <11.0mg/dL, 2-5 yrs with Hb < 11.1 with 3 - 6mg/kg/day of elemental iron • Repeat CBC 1 month into treatment – if hgb increased by 1g/dl then continue for 2 more months, if NOT then further testing recommended • Repeat testing 6 months after successful treatment

7. How Are We Screening? • Pre-intervention Measurement: to assess variability in current screening practices • 9-12 month olds • CBC AND a hemocue (68%) • CBC (28%) • Hemacue alone 4% • Proposals brought to providers on ways to implement uniform screening methods • Which ages to screen patients • Hemocue vs. venipuncture • Coordinating venipunctures with state mandated Pb screening • 2 year olds • CBC AND a hemocue (31%) • CBC (55%) • Hemacue alone 14%

8. Changes Made To Screening • At/ around 12 months: CBC and lead • At/around 18 months: Hemocue • At/around 24 months: CBC and lead

9. Screening P: Tentative consensus made to conduct CBC screening at 12 venous, 18 month hemocue, and 24 months venous D: Providers informed via email of new plan to screen at theses specific ages S: Chart review of recent 12-24 month old visits 18/20 (90%) pts with CBC/Pb screen by 1 year of age 8/12 (66%) pts with f/u hemocue between 15-24 months A: Conducted discussion via email to foster awareness of and buy-in to the new screening protocol

10. Current Protocol • Primary Prevention • Prescribe prophylactic MVI with Iron for all pts 1-3 years to continue for duration of at least 1 year • Screening • CBC at 12 month, Hemocue 18 months, and 24 months CBC and Hemocue • Treatment • Treating all pts under 5 yrs with Hb < 11 with 2 - 4mg/kg/day of elemental iron • Repeat CBC 1 month into treatment – if hgb increased by 1g/dl then continue for 2 more months, if NOT then further testing recommended

11. Treatment • Pre-Intervention Measurement: • 4/16 (25%) patients with iron-deficiency anemia given correct treatment doses of Iron according to AAP • Providers educated on AAP guidelines • Discussion of how we plan to implement/adapt the AAP guidelines, e.g: • Dosage • Anemia definition (i.e. cut-offs by age – vs AAP)

12. Chart Review—Are we appropriately documenting, diagnosing, & treating anemia? • patients age 1 to 3 with dx code of anemia over a 6 month period • Results: • (1) 94% proper “anemia diagnosis • (2) 81% treated with 2-4 mg/kg/day dosing of Fer-in-sol • (3) 81% correctly instructed for follow-up as per documentation • (4) 94% followed up regardless of documentation • (5) 63% documented resolution of anemia (though some still in Tx at time of review) • Goals: Are we reaching them? Documentation might not lead us to believe so…

13. Compliance Problem • Randomly selected group of parents of one to 3 yearolds. • Only 40% took the vitamins nearly all the time (5 times a week or more).   • 50% of the parents surveyed admitted non-compliance (one dose a week orless)

14. Compliance Chart Review • 1 to 3 year olds from each provider • 59% had documentation of child taking Polyvisol with Fe. • All charts documented appropriate screening times for CBC • Reasons for non-compliance

15. Steps Towards Compliance IRON RICH FOOD HANDOUT • English version: revised the handout at a 4th grade reading level using the Flesch-Kincaid Grade Level Index.   • b) Spanish version: translators and Fernandez-Huerta scale between 5th and 6th grade.

16. Future Directions • Finalize consensus screening protocol and achieve provider buy-in • Why are parents not giving the Iron? • Are the Handouts helping? • Chart reviews • Treatment – Are we treating for kids who meet criteria? For patients diagnosed with anemia how is the follow-up – testing at 1 month? Continuing for 3 months at least? • Primary Prevention – Are patients staying on the MVI with Iron? Is it resulting in fewer kids with anemia?

17. Previous PDSA? • Dental Health • 50% documentation of discussion • Developmental or Speech Delay • 50% documented discussion • 0% used sticker’s from last year’s project

18. The Team • Residents • Monique Collier • Brenton Mar • Eliza Auerback • Sarah Schrager • Carol Senkler • Paula Ayora • Dawn Wetzel • John Babineau • Rachelle Gandica • Maja Castillo • Brenda Ritson • Matt Laurich • Patricia Tae • Ola Aganga • Mahbod Mohazzebi • Staff • Joan Mahoney • Maralin Bautista • Candida Rodriguez • Petra Ortiz • Beatrice Frempong • Annes Silver • Annie Hertz • Bill Johnson • Leilani Vinales • Ivelisse Rodriguez • Iliana Torres • Cindy Ferrer • Evelyn Mejia • Denise Connolly-Hoyt • Attendings • Steve Caddle • Adriana Matiz • Mary McCord • Melanie Gissen • Patricia Hametz • Dodi Meyer • Elise Olshen Kharbanda • Mary Zweighaft • Carol Pafundi • Harriet McGurk • Annie Armstrong • Melissa Glassman