Vitamin D Testing

WHY: Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing for Vitamin D levels with 25-OH testing is appropriate only in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections, obese individuals).

Serum levels of 1,25-dihydroxyvitamin D have little or no relationship to vitamin D stores but rather are regulated primarily by parathyroid hormone levels, which in turn are regulated by calcium and/or vitamin D. In vitamin D deficiency, 1,25-dihydroxyvitamin D levels go up, not down. This is a significantly more expensive test with very limited indications: ESRD and complex hypercalcemia/ PTH disorders.

WHAT: Implement a systems-based project to reduce inappropriate vitamin D testing. Project goals are to support appropriate use of lab resources, decrease inappropriate use of vitamin D tests, standardize laboratory policies, and improve lab stewardship.

HOW: Use a multimodal approach to include three components:

• Education (HVC web site info, posters, pocket cards)

• Audit and feedback (HVC teams, attending physicians, pathologists)

• Clinical decision support algorithms and procedures

  • Vitamin D testing will be removed from most order sets across system except Endocrinology, Nephrology

  • Indications for 25-OH Vitamin D testing based upon Endocrine Society guidelines:

    • Risk for osteopenia or demonstrated fractures

    • Osteoporosis, osteomalacia, and other bone diseases

    • Chronic kidney disease stage III or greater

    • Parathyroid or other endocrine or metabolic disorder

    • Individuals with malabsorption and risk of malnutrition (e.g.,celiac disease, Ulcerative colitis, Crohn’s Disease, cirrhosis, cholestatic liver disease, pancreatic insufficiency)

    • Long term anticonvulsant or glucocorticoid therapy

Children on proton pump therapy > 6 months