Barriers to effective diagnosis and management of a bleeding patient with undiagnosed bleeding disorder across multiple specialties: results of a quantitative case-based survey

Figures & data

Figure 1 Schematic of survey content. The case directed to participating critical care specialists began with the second presentation. In contrast, rheumatologists were presented with only the initial patient presentation and subsequent laboratory findings. Where indicated, unique laboratory values and/or clinical parameters were incorporated into the cases presented to participating rheumatologists and critical care specialists.

Abbreviations: aPTT, activated partial thromboplastin time; BP, blood pressure; CBC, complete blood count; ED, emergency department; ENT, ear, nose, throat specialty; HR, heart rate; PT, prothrombin time.

Table 1 Demographic characteristics of survey participants

Characteristic	Specialty
	Hematology ± oncology (n = 51)	Emergency medicine (n = 50)	Geriatrics (n = 50)	Internal medicine (n = 50)	Rheumatology (n = 51)	Critical care medicine (n = 50)
Mean age (years)	48.9	47.2	45.6	49.1	50.6	46.6
Mean duration in practice (years)	18.7	16.1	14.5	19.1	19.3	16.2
Practice description (%)
Mostly office or clinic based	53	6	28	81	96	2
Mostly/exclusively hospital or laboratory based	14	93	8	6	4	75
Equally hospital and office/clinic based	33	0	26	13	0	21
Mostly long-term-care facility based	0	0	32	0	0	0
Mostly hospice based	0	1	2	0	0	0
Other	0	0	3	0	0	2
Office/clinic description ^a (%)
Solo practice	3	100	2	22	21	30
Single-specialty practice	68	0	65	23	44	35
Multispecialty practice	28	0	34	54	34	44
Hospital affiliation (%)
Academic/tertiary care medical center	39	14	32	17	18	36
Private/tertiary care hospital	27	22	18	19	30	22
Community/primary care hospital	34	60	40	63	51	37
VA/government facility	0	3	9	1	0	5
Mean no. patients seen in a typical week	77.1	105.9	75.7	114.8	97.1	67.9

Notes:

a Base respondents consist of only those who practiced in an office or clinic setting at the time of the survey. Therefore, for the emergency and critical care medicine specialties, this base would have been extremely small (n = 2 and n = 10, respectively).

Abbreviation: VA, Veterans Administration.

Figure 2 Recommendations for laboratory tests and hematology consultation across surveyed specialties: first and second presentations. The percentages of physicians in each specialty who would have ordered specific hematologic laboratory tests after each of the case patient’s presentations (A and C) and the percentages who would have ordered repeat coagulation studies and consulted a hematologist after reviewing each set of laboratory results (B and D) are shown. Critical care specialists began their case presentation with the second presentation and were given a different set of vital signs from the other specialties (see Figure 1). Rheumatologists were presented with only the initial patient presentation and subsequent laboratory findings, which included PT and aPTT values that were different from those provided to the other specialties (see Figure 1). In addition, the case patient presented to rheumatologists was evaluated and managed on an outpatient basis. Hematologists were not queried about consulting a hematologist in response to hematologic laboratory results.

Abbreviations: CBC, complete blood count; EM, emergency medicine; heme/onc, hematology/oncology.

Figure 3 Additional tests and consultations recommended after second clinical presentation.

Notes: Percentages of physicians who would have included the respective tests or consultations as part of their evaluation after the case patient’s second clinical presentation are shown. Additional tests that physicians could have selected included platelet function tests, renal ultrasound, upper and lower gastrointestinal series, and “other,” all of which were chosen by 50% or fewer of physicians across specialties.
Abbreviations: CT, computerized tomography; EM, emergency medicine; gI, gastroenterology; UgI, upper gastrointestinal.

Figure 4 Recommendations for repeat coagulation studies and hematology consultation in response to laboratory results after 12 hours of observation subsequent to the case patient’s second presentation.

Notes: The percentages of physicians within each specialty who would have repeated the coagulation studies and consulted hematology in response to the patient’s laboratory results after 12 hours of observation are shown. Laboratory results at this point were remarkable for a further decrease in hemoglobin (to 6.8g/dL [or 8g/dL for the critical care physicians]) and increase in aPTT (to 70 seconds [or 75 seconds for the critical care physicians]).
Abbreviations: EM, emergency medicine; heme/onc, hematology/oncology.

Figure 5 Recommended disposition after initial and second presentations and after 12 hours of observation. (A) The proportion of physicians in each surveyed specialty who would have recommended overnight admission to the general hospital floor or discharge to a skilled nursing care facility/nursing home after the case patient’s first presentation and subsequent laboratory results are shown. (B) The percentage of physicians in each specialty recommending admission to the general hospital floor versus the ICU after the patient’s initial laboratory results upon second admission and subsequent results obtained after 12 hours of observation are shown. See Figure 1 for the summarized laboratory findings.

Abbreviations: EM, emergency medicine; G, geriatrics; HO, hematology/oncology; ICU, intensive care unit; IM, internal medicine.

Figure 6 Prior physician experience with bleeding disorders. Results represent (A) the percentage of physicians in each specialty that had ever discovered (or diagnosed, in the case of the hematologists and hematologist/oncologists) an underlying bleeding disorder and (B) the percentages of those physicians who had specifically encountered “acquired hemophilia.”

Abbreviations: EM, emergency medicine; heme/onc, hematology/oncology.

Table 2 Utilization of and rationale for hematology consultation

	Specialty
	Emergency medicine	Geriatrics	Internal medicine	Rheumatology	Critical care medicine	Hematology ± oncology
Frequency of hematology consultations^a (%)
Never	16	24	25	7	5	–
1–2 times	46	35	41	11	30	–
3–4 times	28	23	23	42	26	–
5+ times	11	19	12	40	39	–
Frequency of consultations received from the emergency department^a (%)
Never	–	–	–	–	–	1
1–2 times	–	–	–	–	–	32
3–4 times	–	–	–	–	–	10
5+ times	–	–	–	–	–	57
Reasons for hematology consultation^b (%)
Any coagulation study outside of normal ranges but not significantly abnormal	0	0	0	12	–	61
Any significantly abnormal coagulation studies	34	55	54	42	–	85
Combination of abnormal coagulation studies with clinical bleeding	87	78	78	65	–	88

Notes:

a Survey participants were asked whether they had ever requested (or received) a hematology consultation for abnormal PT or aPTT in a patient with no history of bleeding diathesis or medications that affect coagulation.

b Summated percentages may exceed 100% because of potential overlap among possible responses.

Abbreviations: aPTT, activated partial thromboplastin time; PT, prothrombin time.