Advancing High Value Health Care
Reducing Unnecessary Vitamin D Screening in an Academic Health System: What Works and When

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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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References (11)

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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.

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