Reducing unnecessary vitamin testing in general practice: barriers and facilitators according to general practitioners and patients

Serum vitamin C status of people in New South Wales: retrospective analysis of findings at a public referral hospital

OBJECTIVES

To examine the relationship between vitamin C status and demographic factors in New South Wales on the basis of serum vitamin C test results undertaken at the central pathology laboratory in Sydney, and to assess associations with age, gender, social disadvantage, and geographic remoteness.

DESIGN, SETTING

Retrospective observational study; analysis of vitamin C test results undertaken at the Royal Prince Alfred Hospital, 1 January 2017 - 31 December 2021.

MAIN OUTCOME MEASURES

Vitamin C status (normal, serum concentration ≥ 40 μmol/L; hypovitaminosis C, 12-39 μmol/L; significant deficiency, < 12 μmol/L); associations of vitamin C status with year of testing, age, gender, socio-economic status (Index of Relative Socio-Economic Advantage and Disadvantage quintile), and geographic remoteness (Australian Statistical Geography Standard); rate of hypovitaminosis C or significant deficiency test results (relative to findings of normal levels; per 100 000 estimated resident population) by Statistical Area 3.

RESULTS

Of 17 507 vitamin C tests undertaken during 2017-2021, 4573 were excluded (multiple tests for individuals); of 12 934 included results, 6654 were for women (51.5%), 9402 for people living in major cities (73.5%), and 81 for people in remote or very remote areas (0.6%). In multivariable multinomial regression analyses, significant deficiency (relative to normal test results) was more likely for men than women (adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.27-1.52); the likelihood of hypovitaminosis C (IRSAD quintile 1 v 5, aOR, 1.35; 95% CI, 1.19-1.53) or significant deficiency (aOR, 2.07; 95% CI, 1.79-2.40) generally increased with postcode-level socio-economic disadvantage. Several of the population areas with the highest low vitamin C rates were areas of greatest disadvantage in NSW.

CONCLUSIONS

The prevalence of vitamin C deficiency among older people and people living in areas of socio-economic disadvantage indicates that population assessment of vitamin C levels would be appropriate.

Vitamin D: determinants of status, indications for testing and knowledge in a convenience sample of Irish adults

Vitamin D deficiency is common in Irish adults, though there is limited research on its determinants, knowledge of vitamin D or indications for testing. We aimed to explore the determinants of vitamin D status in adults and examine knowledge and reasons for testing. The study population comprised adults who had serum 25-hydroxyvitamin D tested by general practitioners request at a Dublin Hospital in 2020. Questionnaires detailing dietary intake, sun exposure, ethnicity, biophysical factors and vitamin D knowledge were sent to a sample stratified by age, sex and vitamin D status. In total, there were 383 participants, mean age 56·0 (sd 16·6) years. Wintertime deficiency disproportionally affected non-white v. white (60 % v. 24 %, P < 0·001). The greatest predictors of deficiency were low vitamin D intake (< 10 μg/d) (P < 0·001) and non-white ethnicity (P = 0·006), followed by sun avoidance (P = 0·022). It was also more prevalent in those with lower body exposure when outdoors. The majority (86 %) identified vitamin D as important for bone health. However, 40 % were tested for non-clinical indications and half were not aware of the recommended daily allowance (RDA). Low vitamin D intake was the most important determinant of deficiency, but ethnicity and sun exposure habits were also significant predictors. The majority had no clear indication for testing and were not aware of the RDA. Public health policies to improve knowledge and vitamin D intake, especially for those of non-white ethnicity and with reduced sun exposure, should be considered.

Clinical chemistry laboratory test overuse in a cardiology clinic: a single-center study

Diagnostic laboratory tests are frequently overused in healthcare entities, leading to an increased strain on laboratory resources, additional workload, and wastage of resources. Continuous monitoring of test ordering behavior is crucial to evaluate clinical necessity. This cross-sectional study aimed to estimate the necessity of ordering clinical chemistry tests in the cardiology clinic of a tertiary center in Saudi Arabia. We retrieved medical records of patients diagnosed with cardiovascular problems admitted at the cardiology clinic in 2020. The frequency and percentages of the ordered tests were calculated upon admission and follow-up, and the difference between necessary and unnecessary tests was compared for each category. Test ordering assessment included cardiac, renal, and liver functions, blood gases, thyroid and diabetic profile, iron indices, hormones, water and electrolytes, and inflammatory markers. The results showed a large number of clinical chemistry tests ordered without clinical necessity. While the number of necessary tests was significantly higher than that of unnecessary tests, 21% of the tests ordered between June-December 2021 at the center were unnecessary. Further studies are necessary to identify driving factors and develop strategies to reduce the overutilization of diagnostic laboratory tests in clinical practice. Eliminating this phenomenon will reduce the risk of unnecessary medical interventions and associated costs, improve patient outcomes, and reduce the overall burden on the healthcare system.

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

Background

Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects.

Methods

We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated.

Results

Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy.

Conclusions

Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.

Vitamin D levels in primary care patients: correlations with clinical, seasonal, and quality-of-life parameters

BACKGROUND

The prevalence of vitamin D deficiency varies across countries and few data exist in the adult population in Greece.

OBJECTIVES

To assess vitamin D levels in unselected patients from primary care and to investigate possible correlations with clinical, seasonal, and quality-of-life parameters.

METHODS

In this cross-sectional study, 389 consecutive patients were included. They were grouped according to vitamin D status as vitamin D deficient (<20 ng/mL) and vitamin D sufficient groups (≥20 ng/mL). Demographic, Epworth Sleepiness Scale (ESS), Athens Insomnia Scale (AIS), Beck Depression Inventory (BDI), and Fatigue Severity Scale (FSS) scores were measured and compared between groups.

RESULTS

Vitamin D deficiency (<20 ng/mL) was observed in 50.4% of the cohort. Female gender (76% vs 66%, P = 0.026), obesity (42% vs 26%, P = 0.005), and hypertension (55% vs 43%, P = 0.023) were higher in the vitamin D deficiency group compared with the group without deficiency. After multiparametric adjustments (for age, gender, obesity, comorbidities, and seasonality), hypertension (odds ratio [OR] = 2.338, 95% confidence interval [CI] = 1.257-4.349, P = 0.007), excessive daytime sleepiness (ESS >10; OR = 3.345, 95% CI = 1.124-9.948, P = 0.029), depressive symptoms (BDI >10; OR = 3.769, 95% CI = 0.984-14.443, P = 0.04), and fatigue (FSS >36; OR = 7.157, 95% CI = 0.855-59.877, P = 0.04) showed significant independent associations with vitamin D deficiency in specific subgroups of patients.

CONCLUSION

A large proportion of patients in primary care had vitamin D deficiency, independently associated with hypertension, sleepiness, depressive symptoms, and fatigue. Further research is needed in order to determine the role of vitamin D in these patients.

Conflict of Interests in the Scientific Production on Vitamin D and COVID-19: A Scoping Review

The use of scientific evidence to support the process of formulating and implementing public policies might be biased by studies funded by the pharmaceutical and food industry, which more often than not meet corporate interests. This review aimed to analyze the occurrence of conflict of interest (COI) in academic production regarding vitamin D and COVID-19, considering the facility offered during the pandemic for academic publications of heterogeneous quality. A scoping review of observational studies published in Medline, Lilacs, and Google Scholar databases was carried out. The selected studies were published between December 2019 and August 2021, focused on the relationship between vitamin D and prevention or treatment of COVID-19 in non-institutionalized individuals, with no language restrictions. Twenty-nine studies met eligibility criteria. COI was disclosed in five papers and further identified by review authors in eight other papers, meaning COI was present in thirteen papers (44.8%). Studies were funded by companies in the diagnostics, pharmaceutical and food sectors. Conclusions favorable to vitamin D supplementation were more prevalent in papers where COI was identified (9/13, 69.2%) than among papers where COI was not found (4/16, 25.0%). Omissions of disclosure of COI, funding source, and sponsor functions were observed. The identification of possible corporate political activities in scientific papers about vitamin D published during the COVID-19 pandemic signals a need for greater transparency and guideline development on the prevention of COI in scientific production.

Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study

BACKGROUND

Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown.

AIM

To assess the prevalence of low-value pharmaceutical care among Dutch GPs.

DESIGN AND SETTING

Retrospective cohort study using data from patient records.

METHOD

The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription.

RESULTS

Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001).

CONCLUSION

The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.

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

BACKGROUND

Vitamin tests are increasingly ordered by GPs, but a clinical and evidence-based indication is often lacking. Harnessing technology (that is, decision support tools and redesigning request forms) have been shown to reduce vitamin requests.

AIM

To investigate whether the number of vitamin tests may be reduced by providing a multi-level intervention programme based on training, monitoring, and feedback.

DESIGN & SETTING

This was a cluster randomised intervention study performed in 26 primary care health centres (>195 000 patients) in the Netherlands. The relative reduction in ordered vitamin D and B12 tests was determined after introduction of two de-implementation strategies (1 May 2017 to 30 April 2018).

METHOD

Health centres randomised to de-implementation strategy 1 received education and benchmarking of their own vitamin test ordering behaviour every 3 months. Health centres in de-implementation strategy 2 received the same education and benchmarking, but supplemented with educational material for patients.

RESULTS

The number of vitamin D tests decreased by 23% compared to the 1-year pre-intervention period (1 May 2016 to 30 April 2017). 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 for vitamin D test ordering (10% extra reduction, odds ratio [OR] 0.88, 95% confidence interval [CI] = 0.83 to 0.92), but not for vitamin B12 ordering (4% extra reduction, OR 0.96, 95% CI = 0.91 to 1.02). Nationwide, this would result in over €3 200 000 in savings on healthcare expenditure a year.

CONCLUSION

A 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 could be achieved.

De-implementing low-value care in endocrinology

Low-value care exposes patients to ineffective, costly, and potentially harmful care. In endocrinology, low-value care practices are common in the care of patients with highly prevalent conditions. There is an urgent need to move past the identification of these practices to an active process of de-implementation. However, clinicians, researchers, and other stakeholders might lack familiarity with the frameworks and processes that can help guide successful de-implementation. To address this gap and support the de-implementation of low-value care, we provide a summary of low-value care practices in endocrinology and a primer on the fundamentals of de-implementation science. Our goal is to increase awareness of low-value care within endocrinology and suggest a path forward for addressing low-value care using principles of de-implementation science.

Testing and Prescribing Vitamin B12 in Swiss General Practice: A Survey among Physicians

Testing and prescribing vitamin B12 (also known as cobalamin) is increasing in Switzerland but substantial variation among general practitioners (GPs) with respect to testing has been noted. In this study, we aimed at exploring GPs’ mindsets regarding vitamin B12 testing and prescribing. A cross-sectional study was conducted using an online survey distributed by e-mail to Swiss GPs. The questionnaire explored mindsets related to testing and prescribing vitamin B12 in specific clinical situations, as well as testing and prescribing strategies. The questionnaire was sent to 876 GPs and 390 GPs responded (44.5%). The most controversial domains for testing and prescribing vitamin B12 were idiopathic fatigue (57.4% and 43.4% of GPs agreed, respectively) and depressive symptoms (53.0% and 35.4% of GPs agreed, respectively). There was substantial variation among GPs with regard to testing strategies (89.5% of GPS used a serum cobalamin test, 71.3% of GPS used holotranscobalamin, and 27.6% of GPs used homocysteine or methylmalonic acid). Intramuscular injection was the predominantly prescribed route of application (median of 87.5% of the prescriptions). In this study, we focus on discordant mindsets that can be specifically targeted by using educational interventions, and research questions that still need answering specifically about the effectiveness of vitamin B12 for idiopathic fatigue.

Vitamin D retesting by general practitioners: a factor and cost analysis

OBJECTIVES

Vitamin D testing by Primary Care doctors is increasing, placing greater workloads on healthcare systems. There is little data though on vitamin D retesting in Ireland. This study aims to investigate the factors associated with vitamin D retesting by Irish General Practitioners (GPs) and examine the resulting costs.

METHODS

This is a retrospective analysis over 5 years (2014-2018) of GP requested 25-hydroxyvitamin D (25(OH)D) results in 36,458 patients at a major city hospital in Dublin, Ireland. Those with one test were compared with individuals who were retested and samples categorised to determine changes in status between tests.

RESULTS

Nearly one in four patients (n=8,305) were retested. Positive predictors of retesting were female (p<0.001), age (60-69 years, p<0.001), location (Co. Kildare, p<0.001) and initial deficiency (<30 nmol/L, p<0.001) or insufficiency (30-49.9 nmol/L, p<0.001). Vitamin D status improved on retesting, with deficiency halving on first retest (9 vs. 18%, p<0.001) and dropping to 6% on further retests. About 12.2% of retests were done within 3 months and 29% had ≥2 retests within 1 year. 57% of retests were in those initially vitamin D replete (>50 nmol/L). The annual cost of inappropriate testing was €61,976.

CONCLUSIONS

One in four patients were retested and this varied by age, gender and patient location. Over 10% of retests were inappropriately early (<3 months), a third too frequent and over half were in replete individuals incurring significant costs. Clear guidance for GPs on minimum retesting intervals is needed, as well as laboratory ordering systems to limit requests using pre-defined criteria.

Identifying and de-implementing low-value care in primary care: the GP's perspective-a cross-sectional survey

OBJECTIVE

General practitioners have an important role in reducing low-value care as gatekeepers of the health system. The aim of this study was to assess the experiences of Dutch general practitioners regarding low-value care and to identify their needs to decrease low-value primary care.

DESIGN

We performed a cross-sectional study.

PARTICIPANTS

We sent a survey to 500 general practitioners.

SETTING

Primary care in the Netherlands.

PRIMARY AND SECONDARY OUTCOMES

The survey contained questions about the provision of low-value care and on clinical cases about lumbosacral spine X-rays in patients with low back pain and vitamin B₁₂ laboratory tests without an evidence-based indication. We also asked general practitioners what they needed to reduce low-value care.

RESULTS

A total of 182 general practitioners (37%) responded. 67% indicated that low-value care practices are regularly provided in general practice. 57% of the general practitioners have seen negative consequences of low-value care, in particular side effects of medication. The most provided low-value care practices are medication prescriptions such as antibiotics and laboratory tests such as vitamin B₁₂ tests. The most reported drivers are patient-related. General practitioners want to maintain a good relationship with their patients by offering their patients an intervention instead of watchful waiting. Lack of time also plays a major role. In order to reduce low-value care, general practitioners suggested that educating patients on the value of tests and treatments might help. Supporting general practitioners and other healthcare professionals with clear guidelines as well as having more time for consultation were also mentioned by general practitioners.

CONCLUSION

General practitioners are aware of providing unnecessary care despite their role as gatekeepers and have reasons for this. They need support in order to change their practice. This support might consist of better education of healthcare professionals and providing more time for consultation. Local and national media, such as websites and television, could be used to educate patients while guidelines could support professionals in reducing low-value care.

Less is more: Two automated interventions to increase vitamin B12 measurement when long-term proton pump inhibitor and decrease redundant testing

INTRODUCTION

To test the efficacy of two interventions to promote the measurement of serum vitamin B₁₂ (s- vitamin B₁₂) in patients with long-term proton pump inhibitor (PPI) use and to decrease inadequate s-vitamin B₁₂ measurement by implementing a minimum retest interval.

MATERIAL AND METHODS

The Laboratory Information System (LIS) automatically registered s-vitamin B₁₂ when not ordered by General Practitioners to all requests patients with long term (>3years) PPI treatment, and with no s-vitamin B₁₂ testing in the previous year. Through the second intervention, the LIS reported the previous s-vitamin B₁₂ result through an explanatory comment in the report, when the test had been requested in the previous three months. We calculated the new diagnoses of vitamin deficiency (s-vitamin B₁₂ < 200 pg/mL), examined the number of tests needed to detect a new case and investigated the economic cost of each one identified by the intervention. Additionally, we counted the s-vitamin B₁₂ that were requested but not measured, and calculated the savings in reagent.

RESULTS

The strategy added 548 s-vitamin B₁₂ and identified 47 new cases of vitamin B₁₂ deficit. The number of added s-vitamin B₁₂ needed to identify a new case by means of the intervention was 12. The total intervention reagent cost was 1446€, with a cost of 30.7€ per new case. The second intervention avoided unnecessary measurement of 611 tests, with 1613€ savings.

CONCLUSIONS

Through the two automated interventions we improved the diagnosis of vitamin B₁₂ deficiency, and decreased inadequate redundant s-vitamin B₁₂ measurement, cutting unnecessary laboratory costs.

A prospective, cross-sectional study on association of serum vitamin D level with musculoskeletal symptoms and blood pressure in adult population

Background:

Vitamin D is an important vitamin required to maintain an important physiological function of the body. The body should maintain an optimal level of vitamin D to maintain skeletal and metabolic functions. It was observed that inverse relationship is maintained by vitamin D level in the body with musculoskeletal symptoms and metabolic disorders.

Objective:

The study is conducted to associate between serum levels of vitamin D with self-reported symptoms (musculoskeletal) and blood pressure.

Material and Methods:

Venous blood sample was collected from 126 adults with musculoskeletal symptoms. The subjects were stratified based on their vitamin D levels. Groups were tested for the frequency of symptoms and the relationship of different parameters with vitamin D.

Results:

The frequency of subjects in the study was more in the deficient category (<20 ng/dL). In the study, vitamin D was found to have a significant association with “weakness.” Body mass index (BMI), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were found to have an inverse relation with serum vitamin D level.

Conclusion:

The study showed the effect of vitamin D level in musculoskeletal symptoms and inverse association of vitamin D with BMI and blood pressure.