From the 2022 HVPA National Conference
Nessreen Mestari MPA (NYC Health + Hospitals), Daniel Alaiev BBA, Da Wi Shin BE, Mona Krouss MD, Hyung Cho MD, Joseph Talledo MS, Sigal Israilov MD
Testing for 25-hydroxyvitamin D deficiency has spiked in recent years despite the U.S. Preventive Services Task Force stating there is insufficient evidence to assess the benefits or harms of screening in asymptomatic adults. A Choosing Wisely retrospective analysis of claims data reported only a marginal reduction in low value vitamin D testing on a national level, through the use of recommendations alone. Electronic Health Records (EHR) interventions with clinical decision support, including hard stops, have been shown to be the most effective in achieving a sustained reduction for unnecessary vitamin D testing.
Our objective was to achieve a sustained reduction, defined as greater than six months, of unnecessary 25-hydroxyvitamin D testing and repeat orders. This was done through implementation of clinical decision support tools (CDSTs) and a best practice advisory (BPA) at NYC Health + Hospitals, the nation’s largest urban safety net system.
Two different CDSTs were implemented across inpatient and outpatient settings, with different recommendations. The BPA was used to address unnecessary repeat testing within three months populated with the most recent test results and a recommendation that retesting is unlikely to change clinical management. Given that the literature states the use of recommendations alone is not effective, we have opted to incorporate education into the EHR for maximum impact. Our outcome measure was the rate of 25-hydroxyvitamin D ordering per 1000 patient days in the inpatient settings and per 1000 patient encounters in the outpatient setting. Pre-intervention period (6/17/20 to 6/13/21, 362 days) was compared to the post-intervention period (6/14/21 to 4/8/22, 299 days). Results were compared with an unpaired t-test assuming unequal variance.
A sustained reduction in 25-hydroxyvitamin D was observed across both inpatient and outpatient settings. In the inpatient setting, ordering rates decreased from 6.38 to 3.75 per 1000 patient days (41% reduction, p < 0.001). In the outpatient setting, ordering rates decreased from 33.71 to 18.87 per 1000 patient encounters (44% reduction, p < 0.001).
Despite the lack of conclusive evidence for the benefits for Vitamin D screening in asymptomatic adults, a significant proportion of patients continue to be screened inappropriately. Our intervention closed the knowledge gap of the appropriate versus inappropriate indications for 25-hydroxyvitamin D testing in a large urban safety net system. By incorporating education in the EHR using a statement linking the guidelines, as well as creating a BPA for repeat testing, we were successfully able to reduce overuse. Our study showed that together, education and targeted alerts, can achieve over a 40% reduction.
Given the success of alerts in the EHR with educational components, similar approaches can be adopted in other health systems to reduce 25-hydroxyvitamin D and other unnecessary testing. This can help reduce costs both directly from the initial test and associated downstream testing.