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EMR Order Alert Significantly Decreases Vitamin D Testing at Kaiser Permanente

Adhering to clinical guidelines improves utilization of laboratory testing

Identification and treatment of vitamin D deficiency is important for musculoskeletal and extra-skeletal health. There are well-defined clinical indications for serum vitamin D testing of at-risk populations, including osteoporosis, malabsorption, fracture, limited effective sun exposure, obesity, and institutionalized individuals, among others. In these individuals it is appropriate to measure vitamin D to determine the dose of oral vitamin D supplementation to reach target levels. Repeat testing to assure replenishment is also warranted.

However, there is little evidence to support broad-based screening for vitamin D deficiency in otherwise healthy individuals. Normal risk adults do not need assessment of vitamin D levels; they need appropriate dietary intake of vitamin D. Nonetheless, and despite the recommendation of evidence-based guidelines, vitamin D testing has significantly increased nationwide.

Nowhere was the increased utilization of vitamin D testing more evident than at Kaiser Permanente in Northern California, where volume increased 224 percent over the course of 3 years, outstripping the population growth of 2 percent by 222 percent. The increased testing was evenly distributed across the region and disproportionally increased compared to other baseline tests such as those for complete blood count and electrolytes. 

Because there had been no significant change to guidelines for testing — i.e., clinical indications or at-risk populations — that require vitamin D testing, the increased utilization likely arose from the extensive media coverage of conflicting and non-conclusive studies associating vitamin D levels with a wide spectrum of illness and disease. Despite the lack of evidence and expert recommendation, it seems plausible that heightened public awareness/concern had driven the increased testing. 

The test for vitamin D deficiency had been steadily increasing in frequency at Kaiser until Julia Drees, Ph.D., technical director of chemistry, and Tom Lorey, M.D., laboratory director, and their colleagues decided to confront what they hypothesized was inappropriate utilization due to widespread misunderstanding of test indication. Drees believed that much of the testing could be attributed to routine screening of otherwise healthy adults. The regional laboratories were performing approximately 2,000 vitamin D tests every day and it was time to act, and further growth was not sustainable.

“Vitamin D testing was the poster child of over utilization; it was truly overwhelming how much it was going up year over year. From 2008 to 2011, it went up over 200 percent in frequency,” said Drees, who went on to explain that the highly effective and widely used hemoglobin A1C test took twice the amount of time to grow to half the rate of order frequency as the vitamin D test. Unlike vitamin D, the increase in A1C volumes were accompanied by new indications for A1C testing.

Despite the near-universal popularity of the vitamin D test, there was very little evidence to support its inclusion in general screens for otherwise well patients, according to Drees. Not only was there little research supporting the test’s use in general screens, but the reference points were not population based and were set far too high without a proper medical decision point, making any analysis of patient results or diagnosis more like guesswork, according to Lorey.

He continued, “So we were not only testing individuals that didn’t require testing, we were flagging folks who were clearly not deficient in vitamin D. And combined with all of this, there was already a readily available treatment — or prevention, if you will — taking vitamin D supplements.”

“What you end up with is a lot of hype for what turns out to be a low-value test,” added Drees.

With Drees, Lorey and their colleagues aware of the economic, time and care costs of the test, they decided that a proper utilization initiative was required before their laboratory (and the rest of the system) became more embroiled in the volume of unnecessary testing.

The first step in their plan was to get support from clinical partners, so they went to the physicians most familiar with the issue.

“Getting the endocrinologist on board was critical,” said Lorey, who went on to say that the endocrinologists at Kaiser, being experts in diagnostics and treatment, had also noticed the prevalence of the vitamin D test and were willing to lend their support.

The team then presented their plan to administrators at the executive level who — once brought up to speed — supported the initiative to go forward with placing a best practice alert in the electronic medical record.  Displayed at the time of test ordering, the alert simply reminds providers that routine screening of healthy, low-risk individuals for vitamin D deficiency is not recommended. The alert also includes a recommended daily intake of 600 to 800 international units of vitamin D.  

Clinicians were quick to correct course. Within several months, vitamin D testing volumes had decreased by 40 percent, a reduction that has been sustained over time. Because the alert was passive and simply advised of appropriate indications for testing, it seems clear that vitamin D testing in Northern California Kaiser was often being added as a routine screening test to otherwise well patient visits, contrary to indication. 

While there was some “physician push back” with the new pop-up alert, Drees and Lorey were impressed how quickly volumes decreased and how long the reduction has been sustained.  “I think there was a realization among the primary care physicians that this was of no value and was creating an enormous amount of work for them, not to mention potential anxiety and confusion among our patients,” Lorey said. “If you’re told your level [of vitamin D] is low and you Google that, you might all of a sudden jump to the conclusion that you have osteoporosis or rickets or some other disease.”  A simple statement in the test order that the vitamin D testing may not be indicated in their patient is all it took. 

Cost savings to the laboratory approach $1 million annually, though Lorey notes that the real cost savings come in provider and patient time — resources wasted on explaining the test, reviewing and explaining the results, and regardless of results, explaining and recommending appropriate vitamin D intake. “The downstream cost in terms of time sink and distraction of both patients and providers is significant, albeit difficult to quantitate; I think that’s where we’ll find the real savings.”

Considering the larger trends in health care, the evolution to a health system focused on the quality and value of patient care can be achieved through system-wide steps that start with the laboratory working with clinical partners and executives, according to both Drees and Lorey.

“This is an example of a test that has been used in many cases without indication and without benefit to patient health or outcomes,” said Lorey. “It’s ultimately wasteful and represents inappropriate financial stewardship of the health care dollar.”

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