Advancing High Value Health CareReducing Unnecessary Vitamin D Screening in an Academic Health System: What Works and When
Introduction
Vitamin D deficiency is relatively common, with an estimated prevalence between 19% and 77% in the United States.1, 2 Low serum 25(OH)D levels have been associated with increased cardiovascular and all-cause mortality3 and other adverse outcomes.4, 5 Further, vitamin D supplementation is safe and low cost. However, associations between vitamin D supplementation and various outcomes have been mixed or have not been definitive,6 and there is limited evidence that population-based screening for vitamin D deficiency improves outcomes.7, 8
Therefore, in an effort to reduce unnecessary testing, the American Society for Clinical Pathology's Choosing Wisely recommendation states, “Don't perform population based screening for 25-OH-Vitamin D deficiency,”9 noting that laboratory testing is appropriate in higher-risk patients when results will be used to institute more aggressive therapy (eg, osteoporosis, chronic kidney disease, malabsorption, some infections, obese individuals).
A 2015 retrospective analysis of claims data reported that launching the Choosing Wisely recommendations had only a marginal effect in reducing low-value vitamin D testing on a national level.10 However, other studies have shown that specific interventions, such as electronic health record (EHR) decision support (including ‘hard stops’) and choice architecture modifications, such as a modification of laboratory ordering preference lists, can significantly decrease screening.8, 11 These studies looked at overall utilization of vitamin D testing but not its specific effect on screening among patients without high-risk indications. We sought to examine how a health system's quality improvement intervention decreases the use of low-value vitamin D screening using a methodologically rigorous evaluation approach that allowed us to assess which components had the greatest effects on the effectiveness and sustainability of the intervention.
Section snippets
Methods
We conducted a quality improvement intervention to decrease the use of unnecessary vitamin D testing among primary care adult patients at a large academic medical center with 3900 clinicians providing care to more than 2.1 million patients annually. The primary care population for this study included patients 18-64 years of age (mean age, 45 years [interquartile range, 34-56]), of which 59% were women and 77% were white. This activity and evaluation was not regulated by the center's
Results
In the 12 months prior to the decision to target vitamin D testing as part of the resource stewardship initiative, 3.0 low-value and 5.0 appropriate vitamin D tests were ordered per 100 patients (Table 2). Low-value orders trended downward, with a negative monthly percentage change of −2.6% (95% CI, −3.7 to −1.6%), whereas potentially appropriate orders increased with a monthly change of 1.3% (95% CI, 0.3 to 2.3%). Beginning at the time the consensus committee was convened in February 2016
Discussion
Our findings suggest that a health system can have positive and sustained effects on reducing unnecessary testing through education and EHR decision support. Moreover, by using an interrupted time-series approach, we were able to examine trends in test reduction during the guideline development process, after the advisory alert was launched, and during a sustainability period. We observed that rates of both appropriate and low-value vitamin D orders were already decreasing prior to the advisory
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(2014) Screening for vitamin D deficiency in adults: U.S. Preventive Services Task Force recommendation statement
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Independent association of low serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels with all-cause and cardiovascular mortality
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Cited by (12)
Vitamin D: Indications for screening and treatment
2019, FMC Formacion Medica Continuada en Atencion PrimariaReducing 25-Hydroxyvitamin D Testing in a Large, Urban Safety Net System
2023, Journal of General Internal MedicineDo not routinely test for vitamin D
2022, The BMJMedical overuse of therapies and diagnostics in rheumatology
2021, Clinical RheumatologyPatterns of clinical care subsequent to nonindicated vitamin D testing in primary care
2020, Journal of the American Board of Family Medicine
Funding: None.
Conflict of Interest: None.
Authorship: CMP and JH contributed equally to this work. All authors had access to the data and a role in writing the manuscript.