A Manifesto

for improving
iron deficiency
anaemia care
in England
2016

Dr Khailee Cheah, Consultant Geriatrician, Royal Free Hospital; Dr Jamie Dalrymple, General Practitioner,
Drayton Medical Practice; Dr Andrew Goddard, Consultant Gastroenterologist, Royal Derby Hospital;
Keith Hanks, British Kidney Patient Association; Dr Duncan Jenkins, Specialist in Pharmaceutical Public Health
at Dudley Office of Public Health; Professor Phil Kalra, Consultant Nephrologist, Salford Royal Hospital;
Rod Mitchell, Crohns in Children Research Association; Joanna Pearce, Crohns and Colitis UK;
Michael Sobanja, NHS Alliance; Dr Wayne Thomas, Consultant Haematologist, Derriford Hospital;
Edwina Towning, Kidney Research UK; Iain Wittwer, Specialist Nurse Practitioner, Churchill Hospitals,
Oxford and Anaemia Nurse Specialist Association

The Anaemia Manifesto is fully sponsored by Vifor Pharma Ltd. Vifor have been involved in the initiation of the Manifesto,
its content, publication and in the selection of the authors.
Summary

Manifesto item What needs to be done?

1. Define overarching best practice principles Achieve consensus on key principles for diagnosis and
management of iron deficiency anaemia (IDA) in England

Ensure specific practice guidelines for IDA are developed

by the National Institute for Health and Care Excellence
(NICE)

2. Tailor services locally Review local practice and identify areas for improvement

Identify a local IDA champion within every acute care

hospital

Develop clearly understandable local care pathways for

IDA, including referral criteria for primary care (where
required)

Develop a Best Practice Tariff for IDA management that

requires local service improvements

3. Develop the evidence base Conduct long-term IDA treatment trials focused on major
mortality and morbidity endpoints

Perform health economics analyses on the cost-

effectiveness of improving IDA management

4. Educate HCPs and patients Develop e-learning packages for healthcare professionals
(in primary and secondary care) who manage patients with
or at risk of IDA

Create multi-format patient education materials to

empower people with or at risk of IDA

5. Define and measure success Develop a dashboard of appropriate metrics to measure

performance in IDA care

Include some or all of these metrics within formal

assessment and remuneration mechanisms for care
delivery in England (e.g. NICE Quality Standards; Quality
and Outcomes Framework [QOF])

Manifesto oversight Put in place a cross-disciplinary working group to oversee

implementation of the Manifesto implementation
is expected to be cost neutral, because reductions in
emergency care costs will offset the outlay

Proposals on who should be responsible for each Manifesto item are provided within

NOTE: Although this Manifesto provides action items for IDA care in England, many of the recommendations
could be adapted for the other nations of the UK.

2SUMMARY
Introduction

Anaemia occurs when red blood cell (RBC) production is decreased, RBC destruction is accelerated, or RBCs
are lost due to bleeding.1 The most common type of anaemia is IDA, with a prevalence of 25% in adult men
and post-menopausal women.2 There are three predominant causes of IDA:13

Blood loss (e.g. heavy menstrual bleeding, gastrointestinal [GI] bleeding);

Inflammation as seen in anaemia of chronic disease (e.g. chronic kidney disease [CKD], inflammatory
bowel disease [IBD]; chronic heart failure [CHF]); and

Low iron intake or malabsorption.

The occurrence of IDA is often related to one of a variety of other diagnoses, and hence IDA management
may reside with GPs or with a range of different specialties.

IDA can have a substantial impact on patients health, sleep and functioning.47 As a result, it may significantly
reduce quality of life (QOL).4 The treatment of IDA has been shown to improve patients QOL in randomised
controlled trials across several conditions (e.g. IBD, CHF and heavy menstrual bleeding).810 Treatment also
improves symptomatic measures, such as exercise capacity.11 Despite this, IDA is under-diagnosed and under-
treated in England.12,13 There are many possible reasons for this, including insufficient surveillance of at-risk
groups by healthcare professionals (HCPs), lack of understanding of the potentially severe consequences of
not treating IDA, lack of responsibility for IDA by one specialty, inadequate referral and follow-up pathways,
and insufficient use of appropriate therapies.

The impact of under-diagnosis and under-treatment is felt not just by patients but also at system level.
Recent Hospital Episode Statistics (HES) data showed that the total cost of IDA management in England was
65.6 million in 2014/15 equivalent to 310,900 per CCG. With appropriate interventions in primary and
secondary care, many IDA patients can be kept out of hospital.15 However, emergency admissions for IDA are
rising, and there are now more than 17,000 such admissions every year in England, with an associated cost of
28.4 million.14 To put that into context, there are more emergency admissions for IDA than for hypertension,
and almost half the number that there are for diabetes complications (primary diagnosis).16 On average, each
emergency IDA admission is estimated to cost 1,165 more than a day case admission (1,640 vs 475,
respectively).14

Overall, IDA management and outcomes are suboptimal in England, and significant numbers of patients are
affected. Something can and must be done. This Manifesto describes key priorities with five areas for action.
We believe that the changes discussed can be implemented in a cost-effective manner, with much of the
outlay for service improvement offset by reductions in emergency care costs.

INTRODUCTION 3
1. Define Overarching Best Practice Principles

Current situation
There are several clinical guidelines available for the diagnosis and management of IDA. However, because
IDA is typically secondary to other conditions, most are specific to the primary diagnosis for example,
the British Society of Gastroenterology (BSG) guidelines, intended primarily for gastroenterologists;2 the
Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, for HCPs managing patients with CKD;17
the British Society of Paediatric Gastroenterology, Hepatology and Nutrition guidelines, intended for HCPs
managing children;18 the British Committee for Standards in Haematology guidelines for the management
of IDA in pregnancy;19 the NICE guidelines for blood transfusion;20 the National Comprehensive Cancer
Network guidelines for HCPs managing cancer or chemotherapy-induced anaemia;21 and the European
Society of Cardiology guidelines for HCPs managing acute and chronic heart failure.22 In addition, there are
local guidelines intended for specific regions, such as the Manchester Anaemia Guide.23 However, while
there is a Clinical Knowledge Summary for IDA,24 NICE have not provided any national, cross-specialty
guidelines for this disorder (although anaemia management is discussed in guidance documents for some
other conditions, such as CKD).25
Furthermore, the available guidelines are often not followed. For example, although the BSG guidelines
recommend that all patients with IDA should receive iron replacement,2 the recent UK IBD Audit found
that only 44% of patients admitted to hospital with IDA secondary to ulcerative colitis actually received
treatment.26
Following guidelines is important not just in ensuring that IDA is treated, but also that it is diagnosed
in the first place. IDA can easily be missed, particularly in primary care, and clinical surveillance among
HCPs in England is failing to adequately detect it.12 There is evidence to show that the introduction and
implementation of clear IDA guidelines could increase the number of patients evaluated and improve the
detection of underlying causes.27

What needs to change?

Owing to the varied causes and settings in which IDA may be encountered, we do not advocate a single
guideline for all aspects of diagnosis and management. However, there are broad best-practice principles
that could be shared across all HCPs managing patients with or at risk of IDA. These include principles
in surveillance, diagnosis, investigations, disease management and follow-up. In addition, given the high
prevalence of IDA, it should have greater recognition in NICE guidelines.

What must be done to achieve this? Who should be responsible?

Achieve consensus on over-arching principles Medical specialty societies*

for IDA diagnosis and management in England
A cross-specialty clinician group should be created
to lead this exercise and publish the outputs
The impact of this consensus should be assessed
using relevant quality standards (see Manifesto
point 5), measured before and after publication

Ensure specific practice guidelines for IDA are Lobbying of NHS England by patient
developed by NICE associations and medical specialty societies*
Both HCPs and patients can play a key role
in advocating for this development

*Such as the British Society of Gastroenterology, Primary Care Society for Gastroenterology, Renal Association, British Renal Society, British
Society for Haematology, British Cardiovascular Society, British Geriatrics Society, Royal College of General Practitioners, Anaemia Nurse
Specialist Association, etc. Including, but not limited to, the British Kidney Patient Association, Kidney Research UK, Crohns and Colitis UK,
and Crohns in Children Research Association

4 1. DEFINE OVERARCHING BEST PRACTICE PRINCIPLES

2. Tailor Services Locally

Current situation
IDA care in England is highly heterogenous, for several reasons:
1. Many sufferers remain undiagnosed,12 or may not be appropriately referred from primary to specialist
care following an initial diagnosis (e.g. because the GP is unsure who to refer to, or due to variations
in IDA treatment across local services).13
2. There is a lack of consensus on the cut-off levels for anaemia (haemoglobin) and iron deficiency
(various markers) that determine whether a patient should receive further investigation and treatment.2
3. IDA can be secondary to a variety of primary diagnoses that may influence its treatment.2,17,18,21,22
4. Management may be led by a GP or by one of number of different specialties, each of which may
follow their own diagnosis and treatment guidelines.2,17,18,21,22
Finally, from a logistical perspective, care pathways currently differ widely from area to area, and even
from practice to practice, depending on the experience and knowledge of GPs and service delivery in
secondary care.
This service heterogeneity, allied to a lack of awareness among HCPs, can result in a failure to take
responsibility for long-term care in IDA.

What needs to change?

It is essential that IDA patients are (1) recognised and diagnosed, (2) given appropriate treatment, and
(3) followed up in the long-term. We acknowledge that there cannot be a one size fits all answer given
that IDA is managed in many different settings, and that clinical practice may vary between specialties
and geographies. Hence, services must be tailored to fit local practice patterns. Clinical leadership and
coordination is required to drive local change and then to direct these care pathways in the longer term.

What must be done to achieve this? Who should be responsible?

Review local practice and identify areas for improvement Clinical commissioning groups (CCGs)
A summit meeting of local stakeholders (HCPs in primary and clinical leads in relevant disease areas
and secondary care, patient groups, commissioners, etc)
may be necessary to achieve this

Identify a local IDA champion within every acute care hospital Hospital clinical leads, in consultation
This HCP will drive necessary change and coordinate with CCGs
local IDA care

Develop clearly understandable local care pathways for CCGs and appropriate specialists, with
IDA covering both primary and secondary care, including guidance from the local IDA champion
referral criteria from primary care (where required) see
case study below
All IDA patients should be covered, including those not
managed by the specialties that most commonly see IDA
patients, such as gastroenterology and nephrology*

Develop a Best Practice Tariff for IDA management NHS Improvement

that requires:
Evidence that service providers and commissioners
have agreed a local plan;
Identification of an IDA champion;
Data collection and monitoring.

*For example, heart failure patients

2. TAILOR SERVICES LOCALLY 5

 Case study: Manchester Anaemia Guide23
This local care document covers all patients with suspected anaemia in the Manchester area and provides guidance
on appropriate diagnostic tests and management strategies. It includes specific, detailed recommendations for the
investigation and treatment of IDA. For example, the document notes that all patients with IDA should commence
iron therapy.
Furthermore, to aid GPs, criteria for referral to specialist care are given:
Patients with no gastrointestinal (GI) symptoms and no obvious cause for their IDA (such as heavy menstruation)
should be referred to an appropriate specialty;
Patients with GI symptoms should undergo a careful history / examination, and coeliac screening, with urgent
cancer referral for those meeting criteria.
This guide (and others like it) provides a potential model for local IDA care pathways across England. However,
more localised documents can go even further than the Manchester guide in setting out precise management and
referral pathways.

6 2. TAILOR SERVICES LOCALLY

3. Develop the Evidence Base

Current situation
Much high-quality research has been performed in recent years to understand the causes of IDA23 and
its impact on health, functioning and QOL.47 Furthermore, treatments such as iron and erythropoietin
have been extensively studied and shown to improve anaemia, exercise capacity and QOL.2,811,17,28
However, a number of important epidemiological, clinical and health economic questions remain
unanswered. For example:
Epidemiological: What is the incidence and prevalence of IDA in England (diagnosed and undiagnosed)?
Clinical: What effect does correcting IDA have on hard endpoints, such as cardiovascular events
and mortality?
Health economic: What are the direct and indirect costs of IDA to the economy and can these be
reduced through improvements in care (e.g. by reducing emergency admissions, improving workplace
productivity, etc)? How cost effectively can these improvements be made?
In addition, many other key research questions remain unanswered, such as those laid out by NICE for
anaemia management in CKD.25

What needs to change?

Further research is required to answer these questions, and they should be prioritised by academic researchers,
clinicians and drug manufacturers with an interest in IDA. We recognise that this is a global rather than
England-specific issue, but call on researchers in this country to play a leading role in improving the current
evidence base.

What must be done to achieve this? Who should be responsible?

Conduct long-term IDA treatment trials as a priority, focused National Institute for Health Research;
on major mortality and morbidity endpoints, as well as local- researchers; drug manufacturers
level studies assessing the real world impact of IDA and its
treatment

Perform health economic analyses to better understand Researchers; drug manufacturers

the potential cost effectiveness of improving anaemia care,
relating to both patients (e.g. improved outcomes and QOL)
and system benefits (e.g. reduced emergency admissions and
GP visits)
Could be run at the level of a single CCG or for the whole
country (e.g. based on HES data see case study below)

Case study: A cost analysis based on HES data29

The Ferronomics analysis used HES data for England for the year 2012/13 to identify some important cost issues
relating to the management of IDA. Key findings were that: the annual cost of managing IDA was 55.5 million; and
each of the ~15,000 emergency admissions per year cost an estimated 1,013 more than an elective admission (1,627
vs 614, respectively), including HCP time, drug and procedure costs, and excess bed day fees. Hence, reducing
emergency admissions through improved diagnosis and management would substantially reduce costs. This analysis
also estimated that 8.4 million (15.2%) could be saved if the CCGs performing below mean levels could elevate their
performance to the mean equivalent to around 80,000 for each of the ~100 CCGs performing at below-mean levels.
Analysis of HES from 2014/15 showed an increase in the cost of IDA management (65.6 million) and an even wider
difference between the cost of non-elective versus elective admissions (1,165).14 As such, the 8.4 million figure stated
above is likely to have increased.
Given the substantial impact of IDA on functioning and QOL,47 further analysis is essential to better understand the
potential cost effectiveness of improving IDA care in England (compared with other potential investments).

3. DEVELOP THE EVIDENCE BASE 7

4. Educate HCPs and Patients

Current situation
Levels of knowledge about IDA vary significantly amongst HCPs, particularly in primary care (where HCPs
have to manage a particularly broad range of conditions). As a result, clinical surveillance may fail to detect
IDA, and some people may remain undiagnosed.12 Furthermore, many patients with IDA are under-treated:
fewer than half of patients in a recent IBD audit had received therapy.26
This may reflect uncertainty and lack of knowledge among HCPs about a wide variety of factors, including:
the need for IDA surveillance in at-risk groups and in those with signs and symptoms of IDA (e.g. fatigue);
the potentially severe physical and psychological consequences of inaction on IDA; diagnostic thresholds
for defining anaemia and iron deficiency; appropriate investigations required to identify underlying causes;
who should take responsibility for IDA patients and referral pathways into specialist care; appropriate
treatment; and long-term monitoring and follow-up.
Improved knowledge among HCPs is also essential if they are to support patients to understand IDA and
its management. Many patients currently lack sufficient understanding to perform adequate self-care or to
drive the medical management of their condition.

What needs to change?

Education is required for all HCPs who manage patients with or at risk of IDA, as well as for patients.

What must be done to achieve this? Who should be responsible?

Develop e-learning packages for physicians Medical and nursing schools; Health Education
and nurses (in primary and secondary care) England;
who manage patients with or at risk of IDA* local education providers (with expertise provided by
Key topics may include: recognising patients medical specialty societies)
at risk for IDA; referral criteria and pathways;
diagnosis and key investigations; treatment
and follow-up guidelines

Create multi-format patient education materials Patient associations (including expert patients)
to empower people with or at risk of IDA to:
Ask the right IDA-related questions of
their HCPs;
Understand their own condition,
e.g. a know your bloods campaign

*Some high-quality educational materials already exist that could be used for this purpose (e.g. the Anaemia Nurse Specialist Associations
Anaemia Academy). Including, but not limited to, the British Kidney Patient Association, Kidney Research UK, Crohns and Colitis UK, and
Crohns in Children Research Association.

8 4. EDUCATE HCPS AND PATIENTS

5. Define and Measure Success

Current situation
As described in points 14 of this Manifesto, there are many areas for improvement in the care of IDA in
England. We have proposed a range of necessary actions. It is essential that the impact of these actions
can be defined and measured, and hence appropriate metrics are needed.
Quality standards for the care of IDA are suggested in the BSG guidelines:2
1. All patients with IDA should be screened for coeliac disease.
2. All patients (other than menstruating women) with IDA and no obvious cause should have appropriate
endoscopy or radiological imaging.
3. All patients should receive appropriate iron replacement.
4. All those not responding to treatment should be considered for further investigation.
5. In all patients being investigated for IDA, reasonable evidence of IDA should be documented in the
patient record based on appropriate markers.
Similarly, the NICE guidelines on managing anaemia in CKD provides a number of implementation priorities
relating to diagnosis, assessment, treatment and monitoring such as regular testing to diagnose iron
deficiency and determine potential responsiveness to iron therapy.25
However, there are several problems with current quality standards. First, there is no single set of standards
that can be used across all IDA care in England. Second, those that are available are inconsistently applied:
for example, an analysis of quality standard 2 from the BSG guidelines (see above) found that the number of
patients receiving upper GI investigation ranged from 20.0% to 98.2% across different CCGs in England.29
Third, available quality standards are not built into the formal assessment and remuneration of IDA care: for
example, there are no IDA-related indicators within the General Medical Services contract QOF.30

What needs to change?

Appropriate metrics are required for the measurement of performance in IDA surveillance, diagnosis,
treatment and follow-up. Where possible, these should be applicable across primary and secondary care
and all IDA patients (irrespective of cause). Formal use of these metrics in the assessment of IDA care
delivery is desirable.

What must be done to achieve this? Who should be responsible?

Develop a dashboard of appropriate, evidence- HCPs; medical specialty societies*

based metrics to measure performance in IDA care
A cross-specialty clinician and public health
group should be created to lead this exercise
Current BSG quality standards could be
a starting point but do not cover all of
the required points (e.g. relating to IDA
surveillance; emergency admissions)
Broader dashboards will be developed
following the recent Carter report31 for
example relating to gastroenterology and renal
medicine and may provide potential long-
term homes for an IDA dashboard

5. DEFINE AND MEASURE SUCCESS 9

Include some or all of these metrics within formal NHS England; medical speciality societies*; patient
assessment and remuneration mechanisms for associations
the delivery of care in England (e.g. NICE Quality
Standards, QOF, CCG Outcome Indicator Set)

*Such as the British Society of Gastroenterology, Primary Care Society for Gastroenterology, Renal Association, British Renal Society, British
Society for Haematology, British Cardiovascular Society, British Geriatrics Society, Royal College of General Practitioners, Anaemia Nurse
Specialist Association, etc. Including, but not limited to, the British Kidney Patient Association, Kidney Research UK, Crohns and Colitis UK,
and Crohns in Children Research Association

Case study: Enhancing Quality and Enhanced Recovery programme in Kent, Surrey and Sussex32
Within this programme, clinical staff in the South East of England have agreed a number of key processes and outcome
measures to ensure patients receive the best possible care in selected conditions (e.g. hip and knee replacement
surgery, heart attack, heart failure and pneumonia). Ideal pathways have been created. The success of NHS Trusts
against individual quality measures can be tracked at www.enhancingqualitycollaborative.nhs.uk/.
Although the current remit is Kent, Surrey and Sussex, there is an opportunity to benchmark performance against the
North West region and internationally with the United States, where similar programmes have been established.
These metrics (and others like them) provide potential models for a national-level dashboard to measure performance
in IDA care.

10 5. DEFINE AND MEASURE SUCCESS

Conclusions and Oversight

Large numbers of people in England are affected by IDA, and yet current
management and hence outcomes are suboptimal. Something can and must
be done. This Manifesto describes the key priorities.

We believe that the changes discussed can be made in a cost-effective

manner, with the outlay for service improvement offset by reductions
in emergency care costs hence, at worst, implementation should be
cost neutral.

Next step: A cross-disciplinary working group (including HCPs from the

various key specialties, patient groups, commissioners, NHS England, NICE,
etc) should be put in place to oversee implementation of the Manifesto.

CONCLUSIONS AND OVERSIGHT 11

References

1. BMJ Best Practice. Assessment of anaemia. Available at: http://bestpractice.bmj.
com/best-practice/monograph/93/overview/aetiology.html. Accessed February
2016.
2. Goddard AF, James MW, McIntyre AS, et al. Guidelines for the management of iron
deficiency anaemia. Gut 2011;60:130916.
3. Huang J, Means R. The frequency and significance of iron-deficiency anemia in
patients with selected concurrent illness. Internet J Internal Med 2008;8:1.
4. Patterson AJ, Brown WJ, Powers JR, Roberts DC. Iron deficiency, general health
and fatigue: results from the Australian Longitudinal Study on Womens Health.
Qual Life Res 2000;9:4917.
5. Gasche C. Anemia in Inflammatory Bowel Diseases. Bremen: UNI-MED Verlag,
2008.
6. NHS Choices. Iron deficiency anaemia. January 2016. Available at: www.nhs.uk/
Conditions/Anaemia-iron-deficiency-/Pages/Introduction.aspx. Accessed February
2016.
7. Murat S, Ali U, Serdal K, et al. Assessment of subjective sleep quality in iron defi-
ciency anaemia. Afr Health Sci 2015;15:6217.
8. Lee TW, Kolber MR, Fedorak RN, van Zanten SV. Iron replacement therapy in in-
flammatory bowel disease patients with iron deficiency anemia: a systematic review
and meta-analysis. J Crohns Colitis 2012;6:26775.
9. Comin-Colet J, Lainscak M, Dickstein K, et al. The effect of intravenous ferric car-
boxymaltose on health-related quality of life in patients with chronic heart failure
and iron deficiency: a subanalysis of the FAIR-HF study. Eur Heart J 2013;34:308.
10. Van Wyck DB, Mangione A, Morrison J, et al. Large-dose intravenous ferric car-
boxymaltose injection for iron deficiency anemia in heavy uterine bleeding: a rand-
omized, controlled trial. Transfusion 2009;49:271928.
11. Anker SD, Comin Colet J, Filippatos G, et al. Ferric carboxymaltose in patients with
heart failure and iron deficiency. N Engl J Med 2009;361:243648.
12. Jones SC, Smith D, Nag S, et al. Prevalence and nature of anaemia in a prospective,
population-based sample of people with diabetes: Teesside anaemia in diabetes
(TAD) study. Diabet Med 2010;27:6559.
13. Mankodi S, Hayee BH, ODonohue J, Reffitt D. Anaemia investigation in practice:
inappropriate, cost inefficient with a risk of missing gastrointestinal cancer. Can we
improve? Clin Med 2010;10:1158.
14. Data on file: Hospital Episode Statistic Data 2014/15, NHS Information Centre for
Health and Social Care (accessed under a commercial re-use license via Harvey
Walsh ltd)
15. Kings Fund. 2012. Emergency hospital admissions for ambulatory care-sensitive
conditions: identifying the potential for reductions. Available at: www.kingsfund.
org.uk/sites/files/kf/field/field_publication_file/data-briefing-emergency-hospi-
tal-admissions-for-ambulatory-care-sensitive-conditions-apr-2012.pdf. Accessed
February 2016.
16. Quality Watch. Focus on preventable admissions Trends in emergency admissions
for ambulatory care sensitive conditions, 2001 to 2013. October 2013. Available at:
www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/131010_
QualityWatch_Focus_Preventable_Admissions.pdf. Accessed February 2016.
19. British Committee for Standards in Haematology. UK guidelines on the manage-
ment of iron deficiency in pregnancy. July 2011. Available at: www.bcshguidelines.
com/documents/UK_Guidelines_iron_deficiency_in_pregnancy.pdf. Accessed
March 2016.
20. National Institute for Health and Care Excellence. November 2015. NICE guide-
lines 24: Blood transfusion. Available at: www.nice.org.uk/guidance/ng24. Ac-
cessed March 2016.
21. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology.
Cancer- and chemotherapy-induced anemia. February 2015. Available at: www.
nccn.org/professionals/physician_gls/pdf/anemia.pdf. Accessed April 2016.
22. European Society of Cardiology. Acute and Chronic Heart Failure. 2012. Available
at: http://eurheartj.oxfordjournals.org/content/ehj/33/14/1787.full.pdf. Accessed
March 2016
23. Central Manchester University Hospitals NHS Foundation Trust. The Manchester
Anaemia Guide. March 2013. Available at: www.cmft.nhs.uk/media/499600/man-
chester%20anaemia%20guide.pdf. Accessed February 2016.
24. National Institute for Health and Care Excellence. Clinical Knowledge Summaries:
Anaemia - iron deficiency. February 2013. Available at: http://cks.nice.org.uk/anae-
mia-iron-deficiency. Accessed April 2016.
25. National Institute for Health and Care Excellence. 2015. NICE guidelines 8: Chronic
kidney disease: managing anaemia. Available at: www.nice.org.uk/guidance/ng8.
Accessed April 2016.
26. Royal College of Physicians. 2014. National clinical audit of inpatient care for adults
with ulcerative colitis UK inflammatory bowel disease (IBD) audit. Available at:
www.rcplondon.ac.uk/file/1165/download?token=T9DH7Tp_. Accessed February
2016.
27. Ioannou GN, Spector J, Scott K, Rockey DC. Prospective evaluation of a clinical
guideline for the diagnosis and management of iron deficiency anemia. Am J Med
2002;113:2817.
28. Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al. Beneficial effects of long-
term intravenous iron therapy with ferric carboxymaltose in patients with sympto-
matic heart failure and iron deficiency. Eur Heart J 2015;36:65768.
29. Goddard AF, Phillips C. 2014. Ferronomics. An economic report on the hidden cost
of anaemia management.
30. NHS Employers. March 2015. 2015/16 General Medical Services (GMS) contract
Quality and Outcomes Framework (QOF). Guidance for GMS contract 2015/16.
Available at: www.nhsemployers.org/~/media/Employers/Documents/Primary%20
care%20contracts/QOF/2015%20-%2016/2015%2016%20QOF%20guidance%20
for%20stakeholders.pdf. Accessed February 2016.
31. Lord Carter of Coles. Operational productivity and performance in English NHS
acute hospitals: Unwarranted variations. An independent report for the Depart-
ment of Health by Lord Carter of Coles. February 2016. Available at: www.gov.uk/
government/uploads/system/uploads/attachment_data/file/499229/Operation-
al_productivity_A.pdf. Accessed April 2016.
32. NHS Kent, Surrey and Sussex. Enhancing Quality & Enhanced Recovery website.
Available at: http://www.kssahsn.net/what-we-do/Pages/default.aspx. Accessed
June 2016.

17. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDI-
GO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Sup-
pl 2012;2:279335.

18. British Society of Paediatric Gastroenterology, Hepatology and Nutrition. Diag-

nosis and management of anaemia in children with IBD. January 2015. Available
at: https://bspghan.org.uk/content/new-guidelines-management-iron-deficien-
cy-anaemia-paediatric-ibd. Accessed February 2016.

UK/OTH/16/0073b | June 2016