A new order form for vitamin D tests based on criteria was introduced in April 2015. Marks on the x-axis indicate 4-month intervals.
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Ferrari R, Prosser C. Testing Vitamin D Levels and Choosing Wisely. JAMA Intern Med. 2016;176(7):1019–1020. doi:10.1001/jamainternmed.2016.1929
The study by Rosenberg et al1 illustrates how difficult it may be to achieve substantial reductions in unnecessary testing despite extensive awareness and publication of recommendations from the Choosing Wisely campaign. It may be that, rather than education, physicians need implementation tools built into the system of ordering laboratory or radiologic tests. Examples of this can be a priori criteria introduced onto the laboratory requisition form for a given test (ie, minimal criteria must be met for the test to be ordered), frequency-based restrictions (eg, a test cannot be ordered more often than every 3 months, with the timing of the most recent test monitored by the laboratory), or simply placing the test on a separate ordering form so that it is not captured in a carte blanche approach to test ordering.
In Alberta, Canada, a province with a population of 4.5 million, we have had success with a criteria-based approach to testing vitamin D levels. In 2013, when the Choosing Wisely campaign was in its early stages in Canada, laboratories in Alberta had noted an excessive test volume for vitamin D assays. Therefore, in 2013, laboratory services decision makers approached endocrinology specialists in the province to identify when a 25-hydroxy vitamin D assay was likely to be most useful. The Choosing Wisely campaign had also started issuing guidelines, including the American Society for Clinical Pathology recommendation to avoid performing vitamin D assays except for patients with higher-risk conditions (eg, osteoporosis, chronic kidney disease, and malabsorption) when results could be used to initiate more aggressive therapy.2 Indeed, when adequate supplementation is ensured, testing of vitamin D levels has relatively few indications, that is, clinical conditions for which the results are likely to alter management of a current condition.3,4 To reduce unnecessary testing, we studied the effect of a change in ordering procedure for vitamin D on the number of tests ordered.
Waiver for this study was obtained through Alberta Health Services for collection of aggregate data. Based on these various sources of recommendations, a guideline was formed (Box) and was approved by Alberta Health Services. This guideline led to a separate form being developed and issued by laboratory services. Physicians now had to identify the indication for testing vitamin D levels. Indications other than those identified in the guideline did not allow for testing of vitamin D levels. This new requisition was implemented on April 1, 2015. Before this date, for several years, the number of annual 25-hydroxy vitamin D assays was approximately 310 000 per year (ie, 1 in 14 Albertans). We measured the monthly number of vitamin D order requests before and after introducing a new procedure for ordering tests.
All medically necessary 25-hydroxy vitamin D testing will be supported by Alberta Health. Any 25-hydroxy vitamin D testing that does not meet the testing criteria listed below will be deemed not medically necessary and will not be performed. (Check all that are appropriate for your patient.)
Metabolic bone disease
Abnormal blood calcium level
Malabsorption syndrome (eg, celiac disease, small-intestinal surgery, anticonvulsant agents)
Chronic renal disease
From April 1 to December 31, 2015, subsequent to the creation of a new ordering form, 20 609 vitamin D tests were ordered. During this 9-month period, one would have expected, based on historical data, that 256 027 tests would have been ordered. This intervention thus led to a 92.0% reduction in the number of vitamin D tests ordered, a savings of about $4 million USD per year ($3 million in the period studied thus far) (Figure). Although criteria-based interventions are susceptible to methods that manage to avoid adhering to the requirements, a rebound in test ordering has not been observed 9 months after implementation. Our laboratory ordering system is both paper-based and electronic; thus, this type of intervention can be used in many different systems.
Criteria-based approaches to the implementation of the Choosing Wisely recommendations have been examined in practice for other tests, including the commonly ordered tests for rheumatoid factor antibody and anti-nuclear antibodies, as well as advanced imaging (computed tomographic scan, bone scan, or magnetic resonance imaging) for spinal pain.5,6 Using a criteria-based approach to test ordering not only reduces the number of tests that would be ordered but it does so without missing clinically relevant conditions.
Corresponding Author: Robert Ferrari, MD, MSc (Med), FRCPC, Department of Medicine, University of Alberta, 13-103 Clinical Sciences Bldg, Edmonton, Alberta T6G 2P4, Canada (firstname.lastname@example.org).
Published Online: May 23, 2016. doi:10.1001/jamainternmed.2016.1929.
Author Contributions: Dr Ferrari had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Ferrari.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Ferrari.
Statistical analysis: Ferrari.
Administrative, technical, or material support: Prosser.
Conflict of Interest Disclosures: None reported.
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