The levels of recommendation (Appropriate, Uncertain, Inappropriate) are defined at the end of the "Major Recommendations" field.
Identification
The panel rated it 'appropriate' to perform a routine complete blood count (CBC) at the time of an office visit in patients with an underlying chronic condition (e.g., rheumatoid arthritis, congestive heart failure) who had not received a CBC in the past year. In patients without an underlying chronic condition, it was rated 'appropriate' to perform a CBC if a CBC had not been done in the past 5 years for all women, men aged 50 and older, or those with anemia symptoms (Table 1).
Table 1. Appropriateness of a Routine Complete Blood Count at the Time of an Office Visit
| Comorbidity |
Interval |
Population |
Consensus |
| No chronic comorbidity |
Every 5 years |
Men aged 18 to 49 without anemia symptoms |
Uncertain |
| All women |
| Men aged 50 and older |
Appropriate |
| Men with anemia symptoms |
| Chronic comorbidity |
Yearly |
All |
Appropriate |
Diagnosis
In women aged 18 to 49 with a hemoglobin (Hb) > 12 g/dL, the panel rated it 'inappropriate' to perform any diagnosis and 'appropriate' to just observe. The corresponding threshold for men or women aged 50 and older was a hemoglobin of > 13 g/dL (Table 2).
Table 2. Appropriateness of a Diagnosis Given Patient Characteristics
| Population |
Hb level (g/dL) |
No intervention (just observe) |
Perform basic diagnosis |
Empiric iron |
Refer for GI diagnosis |
Refer for Hematologic work-up |
| Women 18 to 39 years old |
<12 |
Inappropriate* |
Appropriate |
Uncertain |
Inappropriate |
| >12 |
Appropriate |
Inappropriate |
| Women aged 40 to 49 years old |
<12 |
Inappropriate* |
Appropriate |
Inappropriate |
| >12 |
Appropriate |
Inappropriate |
| Women aged >50 (or post-menopausal and 18 to 49) years old or any man |
<13 |
Inappropriate |
Appropriate |
| >13 |
Appropriate |
Inappropriate |
*Uncertain is Hb 11-12 g/dL and no comorbid chronic disease
GI= gastrointestinal
A diagnosis was rated 'appropriate' in women aged 18 to 50 with hemoglobin <12 g/dL (or <13 g/dL in men or post-menopausal women). When an evaluation was indicated, the panel rated the performance of a basic evaluation 'appropriate' (e.g., test stool for occult blood and obtain routine labs or chest x-ray). However, referral to a gastroenterologist or hematologist for a work-up was rated 'inappropriate' (Table 2). The use of an empiric trial of iron therapy in the absence of a diagnostic workup was rated 'inappropriate' in all situations except for women aged 18 to 39.
Management
With respect to management, the panel rated it 'appropriate' to just observe and 'inappropriate' to transfuse or give erythropoietic growth factors in patients with a hemoglobin of >11 g/dL and no anemia symptoms or underlying cardiovascular disease (Table 3).
Table 3. Appropriateness of anemia management options given patient characteristics (non-nutritional anemia)
| Hb (g/dL) |
Cardiovascular disease |
Anemia symptoms |
Age |
Management options |
| Observe |
Transfuse |
Epo/darbo |
| <8.0 |
|
|
|
Inappropriate |
Appropriate* |
Appropriate |
| 8 to 9.4 |
– |
– |
18 to 69 |
Uncertain |
Uncertain |
Appropriate+ |
| – |
– |
70 or older |
Inappropriate |
Appropriate |
| Either CVD or symptoms |
Appropriate++ |
Appropriate |
| 9.5 to 10.9 |
– |
– |
Uncertain |
Inappropriate |
Uncertain |
| – |
+ |
Inappropriate |
Uncertain |
Appropriate |
| + |
– |
18 to 49 |
Inappropriate |
Uncertain |
| + |
+ |
Appropriate |
| – |
– |
Uncertain |
Inappropriate$ |
Uncertain |
| – |
+ |
Inappropriate |
Uncertain |
Appropriate |
| + |
– |
50 or older |
| + |
+ |
Appropriate |
| 11 to 11.9** |
– |
– |
Appropriate |
Inappropriate |
Inappropriate |
| – |
+ |
Uncertain |
Uncertain |
| + |
– |
Appropriate |
Inappropriate |
| + |
+ |
Uncertain |
Uncertain |
| 12 or greater +++ |
|
|
Appropriate |
Inappropriate |
*Uncertain if age 18 to 49, no CVD, and no anemia symptoms
+Uncertain if age 18 to 49
++Uncertain if no anemia symptoms
$Uncertain if age >70 years
**11 to 12.9 if age >70 years
+++ >13 if age >70 years
CVD = cardiovascular disease; epo = epoetin; darbo = darbepoetin
For patients with hemoglobin of 9.5 to 10.9 g/dL, it was rated 'inappropriate' to just observe the patient if the patient had anemia symptoms or cardiovascular disease. If the patient had anemia symptoms, the use of erythropoietic growth factors was rated 'appropriate' (or 'uncertain' if no anemia symptoms were present). The use of blood transfusion was rated 'inappropriate' if the patient had no anemia symptoms, 'uncertain' in the presence of just anemia symptoms, and 'appropriate' if the patient had anemia symptoms and underlying cardiovascular disease.
In patients with hemoglobin < 9.5 g/dL, it was rated 'inappropriate' to just observe (unless the patient had no symptoms, no cardiovascular disease, and was younger than age 70 in which case it was rated 'uncertain'). The use of an erythropoietic growth factor was rated 'appropriate'. Transfusion was considered appropriate in patients aged 70 and older and in those presenting with either anemia symptoms or underlying cardiovascular disease.
In patients with hemoglobin < 8 g/dL, the use of either transfusion or erythropoietic growth factor was rated 'appropriate' and observation was rated 'inappropriate'.
Definitions:
Rating Scheme for Strength of Recommendations
Appropriate: Median ratings between 7 and 9 (without disagreement)
Uncertain: Median ratings between 4 and 6 or if panelists disagreed (when two panelists rated the indication 'appropriate' and at least two rates the indication as 'inappropriate')
Inappropriate: Median ratings between 1 and 3 (without disagreement)
Rating Scale of Appropriateness* (1 to 9)
1 = extremely inappropriate
5 = uncertain
9 = extremely appropriate
*'Appropriateness' was defined as the expected health benefits of the therapy exceeding its expected negative health consequences by a sufficiently wide margin to justify prescribing the therapy.
