Background: Chronic heart failure (CHF) patients with reduced ejection fraction (EF), as defined as EF < 50%, and iron deficiency have shown improvements in symptoms, functional capacity, and quality of life when treated with IV iron, even without overt anemia (1). The FAIR-HF (2009) and CONFIRM-HF (2015) studies showed improvements in New York Heart Association (NYHA) functional class, 6-minute walk test, and left ventricular EF following treatment with IV iron (2). The AFFIRM-HF (2020) study showed a reduction in recurrent hospitalization within a 1-year follow-up period for those treated with IV iron (3). Multiple guidelines were updated in 2017 with a IIb (weak) recommendation for IV iron use in NYHA class II or III patients with iron deficiency (4). However, it is not known what percentage of patients meeting these criteria are receiving the recommended therapy.
Purpose: Our primary intervention consisted of an educational campaign directed towards residents from the Department of Internal Medicine, which included in-person presentations, emails, and posted flyers about new guideline recommendations. We performed chart reviews on all patients admitted with key terms such as “CHF,” “volume overload,” or “heart failure” as the primary reason for admission 6 months before and through 19 months after the primary intervention. Eight months after the initial intervention, an IV iron (ferric gluconate) order set was added within the institution’s electronic medical record (EMR). Rates of proper screening, as defined by transthoracic echocardiogram (TTE) within the past 5 years and iron labs within 1 year, and treatment, as defined by at least 1 dose of IV iron prior to discharge, were obtained via chart review. Patients were excluded only for underlying infection.
Description: Baseline iron deficiency screening for patients admitted for HFrEF exacerbations was 54%. Of those found to have iron deficiency, 32% were treated with at least 1 dose of IV iron prior to discharge, with an average dose of 544 mg. The 30-day readmission rate for recurrent CHF exacerbation treatment was 27%. After intervention, 61% were screened for iron deficiency, of which 41% were treated with at least 1 dose of IV iron, with an average dose of 770 mg. The 30-day readmission rate showed a significant decrease to 14%.
Conclusions: Within the first 7 months, intervention was successful in increasing rates of screening for iron deficiency in HFrEF patients (p = 0.040) but at the 19-month mark, statistical significance had disappeared (p = 0.151). Treatment for those with iron deficiency anemia trended towards improvement at the 7-month point (p = 0.068) but similarly declined by 19 months (p = 0.116). Readmission rates, compared to baseline, continually improved throughout the study period and by 19 months were significantly reduced (p = 0.049). Further follow-up is needed to check the 1-year hospitalization rates for the cohort. Declining screening and treatment rates were attributed to declining awareness as time from intervention increased. The largest decline in screening and treatment coincided with the start of the new intern class which suggests added training at regular follow up intervals is necessary. Overall, treatment with IV iron decreased 30-day hospital readmissions, but continued education is needed to ensure adherence to guidelines and improved patient outcomes.