b 12 supplementation audit n.
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B 12 SUPPLEMENTATION AUDIT

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  1. B12 SUPPLEMENTATIONAUDIT Jonathan Lolljee

  2. Justification for Audit • Many patients on hydroxocobalamin have not had an IFA test • PA patients at increased risk of gastric cancer • Many patients on hydroxocobalamin had a negative IFA test • Do ALL patients with low vit B12 need IM injections for the rest of their lives? • Should they have a choice?

  3. IM vs Oral B12 Replacement Cyanocobalamin taken 2-3 times daily Advantages of tablets NO NEEDLES! Disadvantages of tablets • More expensive • Compliance issues • Unpredictable absorption

  4. Agreed Standards No official guidance available Dr Cuthbert consulted = no concerns re. tablets All patients with low b12: 1] should undergo IFA testing 2] should be offered the option of IM or oral B12

  5. Aims of Audit • Assess if patients on hydroxocobalamin have had IFA analysis performed? • Of the patients on hydroxocobalamin who have had IFA analysis performed, how many are actually positive for this result? • Offer patients with negative IFA the option of switching to cyanocobalamin

  6. Method SystmOne search based on hydroxocobalmin - 78 results IBD excluded - IFA test no result Case-by-case manual check Audit assessment form completed for each case Exclusions criteria: - cancer, GIT Sx, CNS disease - pancreatic insufficiency - congenital b12 deficiency - Hx of gastritis

  7. Results from 1st Cycle • Included cases = 58 patients • Age range 23-92 years • Mean age 68-years old • 18 different RCs to describe b12 deficiency • IFA performed in 48% (28/58) • +ve IFA in 2/28 cases

  8. Conclusions after 1st Cycle • Many patients have an unclear dx • IFA test not routinely read-coded • Many patients could potentially be switched to cyanocobalamin

  9. Actions Taken after the 1st Cycle • Letters sent to 30 cases without IFA test • Letters sent to 26 patients re. potential a switch to oral B12 supplementation • d/w Tracy Burrell (Admin at Holycroft) • d/w Mr McGuffie (AGH Path Labs)

  10. Further Results Of the 30 patients asked to get a BT - 4 non-responders - 6 positive for IFA - 20 negative for IFA 8 / 20 cases with –ve IFA switched Of 26/28 cases with –ve IFA, 5 switched

  11. Results of Second Cycle • Included cases = 56 patients • 8 new cases • IFA performed in 54% (30/56) • +ve IFA in 3/30 cases • Only 1 of 8 new cases had no IFA

  12. Conclusions • My audit has improved management • IFA performed more frequently • More patients diagnosed with PA • Almost 1/3 eligible patients switched

  13. Worthwhile Audit? IM b12 has many advantages vs oral b12 BUT holistically & medically worthwhile

  14. Limitations of Audit • Read-coding limitations • Note-keeping • Poor search strategy • Time limitations • IFA test = sensitivity 60%

  15. Suggestions for Implementation • Annual report of patients on IM B12 • Annual report of patients with -ve IFA • Annual report of patients on oral B12

  16. SUMMARY Patients should have an IFA test if vitamin-b12 deficient Patients negative for IFA should be offered a choice of either parenteral or oral B12 replacement Cyanocobalamin may be especially useful in: - needle-phobic patients - anxious patients - patients with poor mobility (rpt script can be posted)