Quality Initiative Enhances Iron Deficiency Screening, Treatment in Heart Failure

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Introduction of curated materials to assist clinicians was linked to better rates of screening and treatment of iron deficiency anemia among patients with heart failure.

Implementation of a quality improvement initiative significantly increased the screening and treatment rates of iron deficiency anemia (IDA) among patients with heart failure with reduced ejection fraction (HFrEF), according to a recent study.

The rates of screening and treatment of iron deficiency in ambulatory patients with HFrEF were low at two cardiology clinicians in Toronto, Canada included in the study, matching previous findings, and suggesting patients with HF are underscreened and undertreated for IDA.

“The introduction of curated materials to aid clinicians was associated with increased rates of screening and treatment of IDA among ambulatory HFrEF patients,” wrote the investigative team, led by Roslyn Mainland, division of general internal medicine, Queen’s University.

IDA is prevalent in patients with heart failure—those with anemia experience reduced exercise capacity, advanced heart failure, and increased mortality.2 Independent of anemia, iron deficiency has been linked to reduced exercise capacity and quality of life. Recent data from clinical trials confirmed intravenous (IV) iron supplementation can lessen the negative consequences associated with lack of iron, without increasing adverse effects.3

Clinical guideline recommendations, including those from the American College of Cardiology (ACC) and American Heart Association (AHA), recommend patients with HFrEF be screened and treated for iron deficiency with IV iron.4 However, barriers to screening can include a lack of understanding of appropriate screening tests and interpretation of iron studies, provision in IV infusions in the clinical setting, and appropriate follow-up of clinical response to IV iron therapy.2

In the current analysis, a quality improvement initiative, made up of education and curated materials, was provided to assist clinicians in appropriate screening and treatment of IDA in heart failure.1

The first part of the study involved a retrospective chart review to identify the baseline population of patients with HFrEF screened and treated for IDA between January 2018 and 2020. The quality improvement was initiated starting October 2020 to assist the screening process. The second part evaluated the proportion change in screening and treatment between October 2020 and 2021, after the quality improvement initiative was implemented.

Overall, the aim of the quality improvement initiative was to have ≥75% of HFrEF patients screened and treated for iron deficiency after implementation of the curated materials, known as the Pumping Iron Bundle. The materials included an IV iron replacement protocol, a prefilled IV iron order set, a prefilled laboratory requisition form, and a patient information handout.

A total of 379 patients were included in the study: 249 in the pre-intervention cohort and 130 in the post-intervention cohort. Of these respective populations, 124 (49.8%) and 66 (50.8%) had anemia (hemoglobin <130 g/L). Baseline characteristics were similar between the pre-intervention and post-intervention cohorts.

Within the pre-intervention cohort, 45 (36.3%) patients with anemia were screened for IDA and 29 (64.4%) patients exhibited IDA over the 24-month study period. Following the implementation of the quality improvement initiative, nearly 91% (n = 60) of patients with anemia were screened for IDA (P <.001).

However, among the patients with HFrEF and IDA in this cohort, Mainland and colleagues indicated only 17.2% (n = 5) of eligible patients were treated for IDA with IV iron.

Among the post-intervention study set, more than half of screened patients (n = 31) were identified as having IDA. After implementation of the curated materials, approximately 90.3% (n = 28) of patients with IDA in the post-intervention cohort were treated with IV iron (P <.001).

Mainland and colleagues pointed to factors that preceded a successful intervention implementation, including a small number of involved clinicians at a single center, access to an established outpatient infusion clinic, and the ability for monthly check-ins between the clinician and patient.

“Further work is required to identify barriers to screening and treating iron deficiency among HF patients, and to implement strategies to increase rates in both ambulatory and inpatient settings,” they wrote.


  1. Gewarges M, Mainland R, Wilkinson K, et al. Increasing rates of screening and treatment of iron deficiency in ambulatory patients with heart failure with reduced ejection fraction: a quality improvement cohort study. BMJ Open Qual. 2024;13(1):e002584. Published 2024 Feb 23. doi:10.1136/bmjoq-2023-002584
  2. Ebner N, Jankowska EA, Ponikowski P, et al. The impact of iron deficiency and anaemia on exercise capacity and outcomes in patients with chronic heart failure. Results from the Studies Investigating Co-morbidities Aggravating Heart Failure. Int J Cardiol. 2016;205:6-12. doi:10.1016/j.ijcard.2015.11.178
  3. Heidenreich PA, Bozkurt B, Aguilar D, et al. AHA/ACC/HFSA guideline for the management of heart failure: a report of the American college of cardiology/American heart Association joint committee on clinical practice guidelines. J Am Coll Cardiol 2022;79:e263–421
  4. Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al. Beneficial effects of long-term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiency†. Eur Heart J. 2015;36(11):657-668. doi:10.1093/eurheartj/ehu385