Survival After Wait-and-See Approach in Older Patients With Unexplained Iron Deficiency Anemia in Primary Care: A Practice Evaluation

Thea C Heil; Maartje van Oostrum; Elodie Holwerda; Mariken E Stegmann; Barbara C van Munster; Daan Brandenbarg

doi:10.1016/j.jamda.2023.11.005

Survival After Wait-and-See Approach in Older Patients With Unexplained Iron Deficiency Anemia in Primary Care: A Practice Evaluation

J Am Med Dir Assoc. 2023 Dec 13:104887. doi: 10.1016/j.jamda.2023.11.005. Online ahead of print.

Authors

Thea C Heil¹, Maartje van Oostrum², Elodie Holwerda², Mariken E Stegmann², Barbara C van Munster³, Daan Brandenbarg⁴

Affiliations

¹ Department of Geriatric Medicine, Radboud University Medical Center, University of Nijmegen, Nijmegen, the Netherlands.
² Department of Primary and Long-Term Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
³ Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
⁴ Department of Primary and Long-Term Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. Electronic address: d.brandenbarg@umcg.nl.

PMID: 38103569
DOI: 10.1016/j.jamda.2023.11.005

Abstract

Objectives: Guidelines recommend upper and lower gastrointestinal endoscopic evaluation for patients without a clear physiological explanation for iron deficiency anemia (IDA). However, the consequences of watchful waiting in older patients with unexplained IDA in general practice are unknown. The aim of this study was to investigate characteristics and survival of patients with an unexplained IDA in general practice who refrain from medical specialist evaluation.

Design: Historical prospective study.

Setting and participants: Patients aged ≥70 years with IDA coded in their medical records were selected from the Dutch Academic General Practitioner Development Network (AHON) database.

Methods: Based on their medical records, patients with an unexplained IDA were classified as (1) referred for medical specialist evaluation, or (2) no or noninvasive evaluation in general practice.

Results: Compared to patients who were referred for medical specialist evaluation (n = 235, 47.8%), patients who had no or noninvasive evaluation (n = 257; 52.5%) were older (median respectively 79 vs 82 years old, P < .01) and more likely to have congestive heart failure (respectively 17.4% and 26.1%, P = .02) and dementia (respectively 2.6% and 8.9%, P < .01). Two-year survival was significantly higher in patients who were referred for medical specialist evaluation compared to patients who had no or noninvasive evaluation (respectively, 83.9% and 75.5%, P = .02).

Conclusions and implications: Although mortality was significantly higher in the older and more comorbid patients who had no or noninvasive evaluation in general practice, survival was still high in this patient group. Therefore, non-guideline adherence and a wait-and-see approach could be discussed in a shared-decision-making consultation.

Keywords: Colonic neoplasms; decision making; early detection of cancer; general practice; iron deficiency anemia; primary care.