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Improving rates of ferrous sulfate prescription for suspected iron deficiency anaemia in infants
  1. Corinna J Rea1,2,
  2. Clement Bottino1,2,
  3. Jenny Chan Yuen1,
  4. Kathleen Conroy1,2,
  5. Joanne Cox1,2,
  6. Alexandra Epee-Bounya1,2,
  7. Radhika Kamalia1,
  8. Patricia Meleedy-Rey1,
  9. Kalpana Pethe3,4,
  10. Ronald Samuels1,2,
  11. Pamela Schubert1,
  12. Amy J Starmer1,2
  1. 1 Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
  2. 2 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Department of Pediatrics, Columbia University Medical Center-Vagelos College of Physicians and Surgeons, New York City, New York, USA
  4. 4 New York Presbyterian Hospital, New York City, New York, USA
  1. Correspondence to Dr Corinna J Rea, Division of General Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA; corinna.rea{at}


Background Iron deficiency anaemia (IDA) in infancy is prevalent and associated with impaired neurodevelopment; however, studies suggest that treatment and follow-up rates are poor.

Objectives To improve the rate of ferrous sulfate prescription for suspected IDA among infants aged 8–13 months to 75% or greater within 24 months.

Methods We implemented a multidisciplinary process improvement effort aimed at standardising treatment for suspected IDA at two academic paediatric primary care clinics. We developed a clinical pathway with screening and treatment recommendations, followed by multiple plan-do-study-act cycles including provider education, targeted reminders when ferrous sulfate was not prescribed and development of standardised procedures for responding to abnormal lab values. We tracked prescription and screening rates using statistical process control charts. In post hoc analyses, we examined rates of haemoglobin (Hgb) recheck and normalisation for the preintervention versus postintervention groups.

Results The prescription rate for suspected IDA increased from 41% to 78% following implementation of the intervention. Common reasons for treatment failure included prescription of a multivitamin instead of ferrous sulfate, and Hgb not flagged as low by the electronic medical record. Screening rates remained stable at 89%. Forty-one per cent of patients with anaemia in the preintervention group had their Hgb rechecked within 6 months, compared with 56% in the postintervention group (p<0.001). Furthermore, 30% of patients with anaemia in the postintervention group had normalised their Hgb by 6 months, compared with 20% in the preintervention group (p<0.05).

Conclusions A multipronged interdisciplinary quality improvement intervention enabled: (1) development of standardised practices for treating suspected IDA among infants aged 8–13 months, (2) improvement of prescription rates and (3) maintenance of high screening rates. Rates of Hgb recheck and normalisation also increased in the intervention period.​

  • clinical practice guidelines
  • control charts, run charts
  • paediatrics
  • primary care
  • quality improvement

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  • Contributors CJR participated in data analysis and drafted the initial manuscript. CJR and CB helped conceptualise and design the study, co-designed the clinical pathway (CP) and participated in data collection. JCY helped create the measurement plan, implement PDSA cycles, and collected and analysed the data. KC, AE-B, RS and JC gave feedback on the CP, co-designed the intervention and reviewed data at regular intervals. PMR and RK helped to create the measurement plan and the CP and participated in data collection and analysis. KP co-designed the CP and process flow map, as well as PDSA cycles. PS led implementation for nursing, including developing the process map, scripts and letters, and performing education. AJS oversaw design and implementation of the intervention, including measurement development, PDSA cycles and data review, and provided critical feedback. All authors reviewed and revised the manuscript and approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

  • Funding This study has been supported by Boston Children's Hospital Department of Pediatrics Quality Program and the Division of General Pediatrics.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.