Intravenous Iron Prescribing Appropriateness Through Adherence to a Provincial Order Set for Inpatients: A Retrospective Study.

BACKGROUND AND

OBJECTIVES

Iron deficiency anemia (IDA) is common and often responds to oral iron replacement therapy. Intravenous (IV) iron is indicated in those unresponsive to or unable to take oral iron, but at a high cost. Institutions may implement formulary restrictions to minimize cost from inappropriate use. The objective of this study was to assess IV iron prescribing appropriateness measured as adherence to provincial inpatient order set criteria.

METHODS

This retrospective chart review included adult inpatients prescribed IV iron 1 month pre- or post-order set implementation. Patients receiving hemodialysis, in their first trimester of pregnancy, admitted for stays longer than 365 days, and sites with less than 10 patients were excluded. IV iron order set eligibility criteria includes a hemoglobin less than 130 g/L, evidence of iron deficiency or blood loss, and justification for use of IV rather than oral iron. Alignment with the eligibility criteria was compared (1) pre- and post-implementation of the order set and (2) with use of an order set compared to handwritten orders. Iron administration costs and adverse reactions were captured as secondary outcomes. Statistical analysis included descriptive analysis and comparisons, using the 2-proportion z-test, with a significance level of 0.05, completed via Microsoft Excel and SPSS Statistics.

RESULTS

Overall, 607 patients were included, 408 in the pre-implementation group and 199 post-implementation; most admitted for childbirth (26% and 24%), with the majority prescribed iron sucrose (99% and 66%). Two-thirds (64%) of patients met order set criteria (62% pre- and 67% post-order set implementation; P = .246). Use of an order set increased adherence compared to handwritten orders (71% vs 58%, P = .001). Reasons for non-adherence (n = 221) included iron studies unavailable (53%) and unclear indication for IV rather than oral iron (44%), costing $60,639.20 (35% of overall costs). Thirteen patients (2%) experienced an adverse reaction (all mild-moderate).

CONCLUSIONS

Implementation of an IV iron order set did not statistically increase adherence to the eligibility criteria during the study period. Those not meeting criteria may qualify for oral iron or lack an IDA diagnosis, increasing adverse event risk and health care costs. Mandatory order set use, supplemented with targeted education and health system supports (eg, computerized prescriber order entry), may increase alignment with criteria, improving resource stewardship and patient outcomes.