When Andrew Felcher, MD, got a call from the head of the lab to discuss research about the lack of evidence that vitamin-D deficiency screening improves outcomes, he knew it would be the next topic he would focus on in his role as director of evidence-based guidelines for Kaiser Permanente Northwest.
Dr. Felcher has since led work to update the organization’s guideline on vitamin-D screening using evidence from the U.S. Preventive Services Task Force and Choosing Wisely recommendations to avoid screening in patients in the general population. The guideline also noted when it was appropriate to screen, for example, patients with osteoporosis, chronic kidney disease and those on certain medications.
“The evidence from other medical organizations tipped me over the edge to begin to tackle this,” he said. “We were wasting resources for no good reason.”
Updating the guideline was the first step, but Dr. Felcher knew that in order to make a difference, it had to be delivered to doctors at the point of care. So, in spring 2015, they built an alert into the electronic health record (EHR) that required physicians to acknowledge that they had read the guideline in order to move forward with ordering a vitamin-D test.
Dr. Felcher’s team also took a third step – to slightly modify the laboratory ordering preference list to remove a shortcut for ordering a vitamin-D test.
“This part of the intervention had the biggest impact,” Dr. Felcher said. “We didn’t remove the option, but made it slightly less easy to order. Now, it takes one more click in the EHR to order the test. We sent an announcement to doctors to let them know there were no restrictions on ordering the test, but that it would just require a different workflow.”
To determine if this changed ordering habits, Dr. Felcher and his colleagues looked at overall vitamin-D screening rates before and after the intervention and found that total tests decreased from 74 per 1,000 patients to 24 tests per 1,000 patients.
But Dr. Felcher was also concerned whether making it harder to order the test might mean that people who needed it would not get it (the so-called ‘barrier effect’), so he also looked at the appropriateness of the orders. Data showed that inappropriate orders decreased from 44 to 30 percent and appropriate testing rose from 56 to 70 percent. He and his co-authors from Kaiser Permanente Northwest Center for Health Research, Rachel Gold, David Mosen and Ashley Stoneburner, published these findings in the February edition of the Journal of the American Medical Informatics Association. Other important contributors for this project included the director of their laboratory Kevin Foley, PhD, and chief of endocrinology Alistair Bahar, MD.
“This shows that doctors respond when there is good evidence behind a decision,” he said. “Choosing Wisely gives us a lot of confidence that addressing this area head on is evidence-based and really doesn’t decrease quality. It’s the right thing for patients and the health system.”