March 17, 2017

Reducing unnecessary screening for vitamin D deficiency

How changing the electronic ordering system helped patients get the right test at the right time.

More medical testing isn’t always better. In fact, sometimes too much screening leads to increased costs and unnecessary treatment. According to the American Board of Internal Medicine Foundation’s “Choosing Wisely” initiative, that is the case with widespread blood testing for vitamin D deficiency. The test is expensive, and for most people the results won’t make a difference in treatment.

Andy Felcher, MD
Andy Felcher, MD

Andy Felcher, MD, agrees. As physician lead for evidence-based guidelines at Kaiser Permanente Northwest, Dr. Felcher helped design a program to decrease unnecessary or inappropriate vitamin D deficiency screening, and to educate his fellow physicians about who should be screened. In this interview he speaks about the program and explains why, for most people, screening is unnecessary.

Are there a lot of people with vitamin D deficiency?

We really don’t know. Estimates from the U.S. Preventive Services Task Force range from 19 to 77 percent. Part of the problem is that the experts disagree on what constitutes deficiency.

If someone is deficient, would taking a supplement help?

We don’t have a lot of good evidence about supplementation. Studies show older people living in nursing facilities have fewer falls when they take vitamin D, but vitamin D supplements have not decreased the risk of having a fracture, and they have not been shown to prevent or improve other conditions like heart disease and cancer.

So are there patients who should be screened for deficiency?

Experts disagree on who should be screened, but no professional group recommends that we screen everyone.

The Endocrine Society recommends screening-specific groups. The U.S. Preventive Services Task Force says there’s not enough evidence to determine the benefits and harms of universal screening, and the “Choosing Wisely” program says providers should avoid screening low-risk groups, including the general population.

What is the harm in more widespread screening? 

The biggest harm is that it’s a waste of money and resources that could be better spent elsewhere in the health care system. In 2011 Medicare spent $224 million on vitamin D tests for seniors, and much of that testing was likely unnecessary. In our region, we were able to save an estimated $1.4 million annually by decreasing unnecessary testing.

How did you decide what screening is appropriate?

We reviewed the expert recommendations with a group of our own endocrinologists and came up with a list on which most experts agree. These include patients with osteoporosis as well as patients with conditions that make it difficult for their body to absorb vitamin D, for example, patients with calcium or parathyroid disorders, malnutrition syndromes and chronic kidney disease. Patients taking medications that interfere with vitamin D absorption should also be screened — this includes patients taking steroids, anti-epileptics and certain HIV medications.

How did you get providers to stop ordering unnecessary tests?

We started by developing a new regional guideline to educate providers on who should be screened for vitamin D deficiency. Then we wrote a summary of the guideline that would pop up for providers to read before they ordered the test. After reading the guidelines, the clinician could order the test, but an extra click in the electronic ordering system was necessary to do so.

We also removed a shortcut for ordering the vitamin D test from the lab-ordering preference list for all clinicians except endocrinologists, nephrologists and orthopedists — the providers who see patients who are at high risk for deficiency.

So, did the changes in the ordering system work?

Yes. Scientists from the Kaiser Permanente Northwest Center for Health Research compared the number of vitamin D screenings ordered during the six months after the intervention took place to the number ordered during the six months prior to changing the ordering system. Total tests decreased from 74 per 1,000 members to 24 tests per 1,000 members. Inappropriate testing decreased from 44 to 30 percent, and appropriate testing rose from 56 to 70 percent. This saved money and time for patients and the health care system, and also helped educate patients and providers about who should be tested and who shouldn’t.

This is one of the first studies to show how changes in the electronic ordering system can reduce unnecessary vitamin D testing, and it is published online in the Journal of the American Informatics Association.

So what should patients do if they think they are low in vitamin D?

Our own bodies make vitamin D when we are exposed to the sun, so if you’re in a sunny climate, go outdoors. If you live in the Pacific Northwest like I do and don’t get much sunshine, you may want to take a supplement. We don’t have strong evidence yet that supplements improve health, but there are many studies underway looking at this question, and as long as you don’t take more than 4,000 IUs a day, a vitamin D supplement is unlikely to hurt you.

If you’re going to take a vitamin D supplement, make sure to look for the USP (U.S. Pharmacopeial Convention) testing symbol on the label. This means the bottles have been inspected to make sure the amount of vitamin D listed on the bottle matches what’s actually contained in the tablet.

Patients can also make lifestyle changes to get more vitamin D. Patients who smoke should get help quitting because smoking is associated with lower levels of vitamin D. Patients can also increase their intake of foods rich in vitamin D — fatty fish like salmon, poultry, or foods to which vitamin D is added like tofu, orange juice and some dairy products.