Improving rates of ferrous sulfate prescription for suspected iron deficiency anaemia in infants

Corinna J. Rea, Clement Bottino, Jenny Chan Yuen, Kathleen Conroy, Joanne Cox, Alexandra Epee-Bounya, Radhika Kamalia, Patricia Meleedy-Rey, Kalpana Pethe, Ronald Samuels, Pamela Schubert, Amy J. Starmer

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish (US)
Pages (from-to)588-597
Number of pages10
JournalBMJ Quality and Safety
Issue number7
StatePublished - Jul 1 2019
Externally publishedYes


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

ASJC Scopus subject areas

  • Health Policy


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