Laboratory anemia investigation: a question and answer approach for physicians in
Inga Zelvyte, MD, Tamara Zafirova MD, Marie-Louise Lennartsson, DC
Clinical Chemistry Laboratory, County Hospital, Jönköping, Sweden.
E-mail: inga.zelvyte @lj.se
Introduction. Anemia in primary health care is a common and complex problem because it is
often a symptom of an underlying disease. There are different customs for requesting
laboratory tests used to verify and differentiate anemia at primary health care units in
Jönköping County, in Sweden.
Aim. We aimed to improve the utilisation of clinical chemistry laboratory at primary health
care units by creating a flow chart for the laboratory diagnosis of anemia. Special
consideration was given to exclude or verify iron, folate or cobalamin deficiency-related
Methods and study design. The constructed flow chart has started with a redesign of
commonly used request protocol. We have made an insert for physician with four questions
regarding patient’s clinical history. The answers entered into the request protocol determine
the selection of laboratory tests in the algorithm for the diagnosis of anemia.
Results. Forty seven clinically suspected anemia cases from three primary care units
(Öxnehaga, Mullsjö and Gränna) were forwarded to the laboratory of Clinical Chemistry,
County Hospital Ryhov for anemia evaluation.
We have found thirty one cases with haemoglobin concentration below the lower limit of
reference interval. We have then followed the other steps of the algorithm for those cases. The
deficiency of iron, folate or cobalamin deficiency was verified or excluded in twenty six
cases. In addition, we have clarified other reasons for remaining five cases of anemia. Each
investigation took from one to seven days (median 3.5 days) to perform. Moreover, the
individual interpretative comment for each case was introduced for the first time.
Conclusion. Our results suggest that the application of the flow chart for the diagnosis of
anemia may improve utilisation of laboratory service. Our flow chart for the laboratory
investigation of anemia contains a simple algorithm and facilitates the diagnosis of frequently
occurring anemias. However, laboratory diagnosis obtained with the help of this algorithm
should always be reviewed in the context of clinical history of every individual case.