Test ordering in an evidence free zone: Rates and associations of <scp>A</scp>ustralian general practice trainees’ vitamin <scp>D</scp> test ordering

Tapley, Amanda; Magin, Parker; Morgan, Simon; Henderson, Kim; Scott, John A.; Thomson, Allison; Spike, Neil; McArthur, Lawrie; Driel, Mieke van; McElduff, Patrick; Bonevski, Billie

doi:10.1111/jep.12322

Cited by 9 publications

(13 citation statements)

References 25 publications

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“…Therefore, it is not surprising that although 31% of adults in Australia have some level of vitamin D deficiency,13 testing was only 21.4 per 1000 consultations after the new MBS criteria, with a cumulative percentage of 9.1% of patients tested, and no substantial improvement in vitamin D deficiency detection, even among those with some clinical indication. Diverse factors may be responsible for the low frequency and adequacy of test requests, including unfamiliarity with current recommendations, physicians’ resistance to change, coexistence of conflicting recommendations and practice guidelines,3 9 11 lack of tools to help with the decision making, as well as patient characteristics (ie, more frequent tests among females, migrants, elder patients and unemployed, with multiple comorbidities) and practice profile 3 11 31–34. As suggested by Australian GPs, patient request is also, anecdotally, a factor.…”

Section: Discussionmentioning

confidence: 99%

Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS MedicineInsight database

Gonzalez-Chica

Stocks

2019

BMJ Open

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ObjectivesTo assess changes in the frequency of vitamin D testing and detection of moderate/severe vitamin D deficiency (<30 nmol/L) among adults after the introduction of new Medicare Benefits Schedule (MBS) rebate criteria (November 2014), and their relationship to sociodemographic and clinical characteristics.DesignDynamic (open) cohort studySettingPrimary careParticipantsAbout 1.5 million ‘active’ patients aged 18+ years visiting a general practitioner and included in the National Prescribing Service MedicineInsight database.Outcome measuresThe frequency of vitamin D testing (per 1000 consultations) and moderate/severe vitamin D deficiency (%) recorded between October 2013 and March 2016, stratified by the release of the new MBS criteria for rebate.ResultsMore patients were female (57.7%) and 30.2% were aged 60+ years. Vitamin D testing decreased 47% (from 40.3 to 21.4 tests per 1000 consultations) after the new MBS criteria, while the proportion of tests with no indication for being performed increased from 71.3% to 76.5%. The proportion of patients identified as moderate/severe vitamin D deficient among those tested increased from 5.4% to 6.5%. Practices located in high socioeconomic areas continued to have the highest rates of testing, but moderate/severe vitamin D deficiency detection remained 90% more frequent in practices from low socioeconomic areas after the rebate change. Furthermore, the frequency of individuals being tested was reduced independent of the patients’ sociodemographic or clinical condition, and the gap in the prevalence of vitamin D deficiency detection between those meeting or not meeting the criteria for being tested remained the same. Moderate/severe vitamin D deficiency detection decreased slightly among patients with hyperparathyroidism or chronic renal failure.ConclusionsAlthough the new criteria for rebate almost halved the frequency of vitamin D testing, it also lessened the frequency of testing among those at higher risk of deficiency, with only a small improvement in vitamin D deficiency detection.

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Section: Discussionmentioning

confidence: 99%

Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS MedicineInsight database

Gonzalez-Chica

Stocks

2019

BMJ Open

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“…Of studies evaluating repeat tests over time, a quarter of French patients incurred three or more tests in a five year period [30] while 27% of Australian patients incurred three or more tests in a four year period [27] and three or more 25-OH-D tests were ordered for patients in a hospital in Saudi Arabia within one year, with some patients incurring more than six tests [35]. Khalifa et al [35] described Physicians were more likely to order 25-OH-D tests for female patients, older patients, and migrant patients [29,34,36,[38][39][40][41][42]. Ages described as "older" varied by study with tested patients having a mean age of 50 years [29,42], 63 years [38], or older than 65 years [36].…”

Section: Resultsmentioning

confidence: 99%

“…Khalifa et al [35] described Physicians were more likely to order 25-OH-D tests for female patients, older patients, and migrant patients [29,34,36,[38][39][40][41][42]. Ages described as "older" varied by study with tested patients having a mean age of 50 years [29,42], 63 years [38], or older than 65 years [36]. Gowda et al [34] reported that 25-OH-D testing increased with age throughout adulthood.…”

Section: Resultsmentioning

confidence: 99%

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Clinical Management of Low Vitamin D: A Scoping Review of Physician Practices

Rockwell¹,

Kraak²,

Hulver³

et al. 2018

Preprint

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The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies recommend against population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. In order to assess patterns of physician management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and gray literature. Thirty-eight records met inclusion criteria and were summarized in an evidence table. Results from seven countries showed a consistent increase in vitamin D lab tests and related costs. Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term. Variability and controversy were pervasive in many aspects of vitamin D management, shining light on physician practices in the face of uncertainty. Future research is needed is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations.

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“…Rapid point-of-care tests are increasingly being administered by trained staff and health care professionals in pharmacies, hospitals, and clinics [ 93 ]. In the meantime, increasing the awareness among conscious consumers about the potential link between certain nutrient inadequacies and deficiencies and adverse health outcomes has resulted in an increase in the rate of self-testing [ 94 ]. Moreover, the emerging use of self-diagnostic tests by consumers [ 95 ] suggests that consumers are becoming more active in diagnosing and managing their own health.…”

Section: Discussionmentioning

confidence: 99%

Considerations for Secondary Prevention of Nutritional Deficiencies in High-Risk Groups in High-Income Countries

et al. 2018

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Surveys in high-income countries show that inadequacies and deficiencies can be common for some nutrients, particularly in vulnerable subgroups of the population. Inadequate intakes, high requirements for rapid growth and development, or age- or disease-related impairments in nutrient intake, digestion, absorption, or increased nutrient losses can lead to micronutrient deficiencies. The consequent subclinical conditions are difficult to recognize if not screened for and often go unnoticed. Nutrient deficiencies can be persistent despite primary nutrition interventions that are aimed at improving dietary intakes. Secondary prevention that targets groups at high risk of inadequacy or deficiency, such as in the primary care setting, can be a useful complementary approach to address persistent nutritional gaps. However, this strategy is often underestimated and overlooked as potentially cost-effective means to prevent future health care costs and to improve the health and quality of life of individuals. In this paper, the authors discuss key appraisal criteria to consider when evaluating the benefits and disadvantages of a secondary prevention of nutrient deficiencies through screening.

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Test ordering in an evidence free zone: Rates and associations of Australian general practice trainees’ vitamin D test ordering

Abstract: In this first report of associations of vitamin D testing in the GP setting, we found that non-targeted vitamin D testing (testing inconsistent with current guidelines) is widespread in GP trainees' practice. Adoption of more rational testing approaches is needed.

Cited by 9 publications

References 25 publications

Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS MedicineInsight database

Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS MedicineInsight database

Clinical Management of Low Vitamin D: A Scoping Review of Physician Practices

Considerations for Secondary Prevention of Nutritional Deficiencies in High-Risk Groups in High-Income Countries

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