Reducing vitamin D requests in a primary care cohort: a quality improvement study

Abstract

BackgroundSince 2000, vitamin D requests have increased 2–6 fold with no evidence of a corresponding improvement in the health of the population. The ease of vitamin D requesting may contribue to the rapid rise in its demand and, hence, pragmatic interventions to reduce vitamin D test ordering are warranted.AimTo study the effect on vitamin D requests following a redesign of the electronic forms used in primary care. In addition, any potential harms were studied and the potential cost-savings associated with the intervention were evaluated.Design & settingAn interventional study took place within primary care across Leicestershire, England.MethodThe intervention was a redesign of the electronic laboratory request form for primary care practitioners across the county. Data were collected on vitamin D requests for a 6-month period prior to the change (October 2016 to March 2017) and the corresponding 6-month period post-intervention (October 2017 to March 2018), data were also collected on vitamin D, calcium, and phosphate levels.ResultsThe number of requests for vitamin D decreased by 14 918 (36.2%) following the intervention. Changes in the median calcium and phosphate were not clinically significant. Cost-modelling suggested that if such an intervention was implemented across primary care in the UK, there would be a potential annual saving to the NHS of £38 712 606.ConclusionA simple pragmatic redesign of the electronic request form for vitamin D test led to a significant reduction in vitamin D requests without any adverse effect on the quality of care.

Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare

“…There is currently no sufficient evidence of health benefits and harms of testing vitamin D levels. [17][18][19][20][21][22][23][24] Vitamin D testing is indicated in individuals at particularly high risk of abnormal vitamin D levels or related complications, including patients with osteoporosis, hyperparathyroidism, malabsorption, chronic renal failure, or hypocalcaemia or hypercalcaemia, and patients with severe lack of sun exposure or who use medications that reduce vitamin D levels. 25 26 Testing healthy individuals who are not at risk of vitamin D deficiency is not recommended as it wastes resources and can likely lead to unnecessary treatment in a significant subgroup of healthy individuals.…”

“…19 Another more recently published UK study reported a 36.2% reduction in the number of vitamin D tests ordered following the introduction of an electronic laboratory request form, an intervention to reduce the number of unnecessary tests, indicating that at least 36.2% of the tests ordered pre-implementation were likely unnecessary. 17 Only one study quantified the number of vitamin D tests providing no net health benefit in Australia. 20 This study looked at whether the changes introduced in 2013 to restrict rebates for vitamin D testing to a set of relevant clinical indications had resulted in less unnecessary testing.…”

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

“…Several recent studies confirmed that a large proportion of vitamin D tests in primary care lacks a valid clinical indication. 15,27,28 Sustainability. In order to gain understanding of the sustainability of our intervention, we looked at the number of vitamin D tests ordered in the two years following the pilot 'practice improvement project' performed in 11 primary care health-centers (patient population 120.000) in Rotterdam.…”

“…13 A systematic review showed how involving patients through patient-targeted educational materials is effective in decreasing the use of low-value care. 13,14 Further, previous studies showed how redesign of the electronic request form 15 and 3 clinical decision support tools (e.g. guideline development, a 'stop alert' shown to the ordering clinician and removal from the laboratory ordering preference list) 16 reduced vitamin D testing respectively 36 and 30%.…”

“…However, the individual impact of these tools could not be assessed, the follow-up period was limited to 6 months and implementation is only possible in a setting where decision support tools can be integrated in Electronic Health Records. 14,15,16 Therefore, we aimed at other simple intervention strategies that can be implemented in every primary care system and can be evaluated separately. In this study we therefore assess the effect of a GP targeted intervention program based on training, monitoring and feedback to rationalize the vitamin D and B12 test ordering in primary care, and the added value of practice based patient information about vitamins and health.…”