Effectiveness of professional and patient-oriented strategies in reducing vitamin D and B12 test ordering in primary care: a cluster randomised intervention study

Abstract

BackgroundVitamin tests are increasingly ordered by GPs, but a clinical and evidence based indication is often lacking. Harnessing technology, ie, decision support tools and redesigning request forms, have been shown to reduce vitamin D requests.AimCould the number of vitamin tests also be reduced by providing a multi-level intervention programme based on training, monitoring and feedback?Design & SettingIn a Cluster Randomised Intervention Study performed in 26 primary care health-centres (200.000 patients) the relative reduction in ordered vitamin D and B12 tests was determined after introduction of two de-implementation strategies (may 2017-may 2018).MethodHealth-centres randomised to de-implementation strategy one received education and 3-monthly benchmarking of their own vitamin test ordering behaviour. Health-centres in de-implementation strategy two received the same education and benchmarking but supplemented with educational material for patients.ResultsThe number of vitamin D tests decreased 23% compared to the one-year pre-intervention period. For vitamin B12 tests an overall reduction of 20% was found. Provision of patient educational information showed additional value over training and benchmarking of GPs alone, but only for vitamin D test ordering (10% extra reduction, OR 0.88, 95% CI 0.83–0.92, compared to 4% extra reduction for vitamin B12, OR 0.96, 95% CI 0.91–1.02). Nationwide, this would result in over € 3.200.000 saving on healthcare expenditure per year.ConclusionA structured intervention programme, including training and benchmarking of GPs regarding their diagnostic test ordering resulted in a significant reduction in ordered vitamin tests. Additional information provision to patients resulted in a small but still relevant additional reduction. If implemented on a national level, a substantial cost saving can be achieved.

Non-indicated vitamin B12- and D-testing among Dutch hospital clinicians: a cross-sectional analysis in data registries

“…A study among Dutch GPs showed that providing both education and feedback successfully reduced the amount of vitamin tests ordered by 20%–25%. 42 Similar interventions might therefore also be effective among hospital clinicians to reduce (non-indicated) vitamin testing. Alternatively, more emphasis could be placed on the institution of fortification and supplementation guidelines to achieve adequate vitamin B 12 and D intake among the Dutch population.…”

Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands?

“…All project teams performed a structured process evaluation, and all projects obtained ethical approval before the start of their study. Several projects are described in more detail in other papers 14–23…”