title: Improving efficiency and value in health care. Intravenous iron management for anaemia associated with chronic kidney disease: linking treatment to an outpatient clinic, optimizing service provision and patient choice.
abstract: BACKGROUND
  The National Service Framework advocates correction of anaemia in patients with chronic kidney disease (CKD). Oral iron is insufficient, while intravenous (IV) supplementation replenishes and maintains iron stores. In Yorkshire numerous peripheral clinics exist to reduce travel for patients, but patients must travel to the main unit for IV iron therapy. Therefore an outpatient service in tandem with a routine clinic for administration of IV CosmoFer was created.
  
  
  OBJECTIVE
  To evaluate the feasibility and benefits of IV iron therapy in the outpatient clinic during active patient review for CKD patients.
  
  
  METHODS
  A cross-sectional study of patients attending for total dose IV iron (n = 57) at a peripheral clinic. Iron was administered and monitored according to protocol by one of the clinic nurses with medical staff available in the adjoining room. Haemoglobin, ferritin and renal function were recorded pre-infusion and after 4-6 months. Results are given as medians/means +/- standard error.
  
  
  RESULTS
  A total of 76 IV infusions were carried out with no reported side effects or haemodynamic instability. Haemoglobin (median 10.9 vs. 11.3 g dL(-1), P = NS), creatinine and estimated glomerular filtration rate (eGFR) over the 6-month period remained stable. Serum ferritin rose significantly [80.9 +/- 6.2 vs. 186.4 +/- 18.2 g L(-1) (P < 0.001)]. Hospital time saved 380 day case bed hours, doctor hours saved 76 hours, and patient hours saved 3 hours/patient. Cost savings for TDI CosmoFer in peripheral clinic versus in centre therapy and versus sucrose, respectively, for 76 treatments was pound 5749.40 and pound 46,320.80 respectively.
  
  
  CONCLUSIONS
  We have demonstrated, in a resource-limited service, the feasibility and cost-effectiveness of a management care pathway for patients with CKD, in a peripheral clinic, to receive total dose IV CosmoFer without disruption of a functioning renal clinic.
authors.affiliation: Department of Renal Medicine, Hull and East Yorkshire Hospitals NHS Trust, Hull Royal Infirmary and Hull York Medical School, Kingston upon Hull, UK. sunil.bhandari@hey.nhs.uk
authors.forename: Sunil
authors.initials: S
authors.lastname: Bhandari
authors.forename: Sarah
authors.initials: S
authors.lastname: Naudeer
mesh_terms: D000554:Ambulatory Care Facilities / Q000191:economics / Q000458:organization & administration*; D018798:Anemia, Iron-Deficiency / Q000188:drug therapy* / Q000191:economics / Q000209:etiology*; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D017598:Efficiency, Organizational; D005260:Female; D005293:Ferritins / Q000097:blood; D006454:Hemoglobins / Q000032:analysis; D006801:Humans; D007262:Infusions, Intravenous; D007505:Iron-Dextran Complex / Q000008:administration & dosage / Q000191:economics / Q000627:therapeutic use*; D007676:Kidney Failure, Chronic / Q000150:complications*; D007677:Kidney Function Tests; D008297:Male
chemical_list: D006454:Hemoglobins; D007505:Iron-Dextran Complex; D005293:Ferritins