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The benefits of this project
Benefits for Your Patients
- Improved self care
- Avoids unnecessary tests
Benefits for Your Practice
- Fewer phlebotomy appointments needed
- Reduced clinician time to manage results
Benefits for The Planet
- Reduced emissions from unnecessary investigations and patient travel – estimated emissions from one GP phlebotomy appointment 9.9kgCO2e
Opportunity for improvement
National guidance recommends everyone consider taking over-the-counter vitamin D supplements especially those in at risk groups but routine vitamin D testing is not needed.
There are limited reasons for testing Vitamin D but the number of tests taken in the UK has increased more than 10-fold since 2001. Several international guidelines recommend against routinely testing or screening for Vitamin D with no clinical symptoms and no risk of deficiency (including NICE). No studies have shown that Vitamin D screening improved health outcomes.
Each Vitamin D test costs approximately £15 with the total UK spend estimated to be ₤17m. Once the cost of appointments and supplements are added in, the estimated costs are over £130 million per year (over £1bn in the past decade). Since 2013, Vitamin D has been one of the top 20 drugs prescribed in the UK even though the guidance is for over-the-counter supplements.
Vitamin D supplementation does not prevent fractures or falls or have clinically meaningful effects on bone mineral density or strength. The clear exception to this is for the prevention or treatment of the rare conditions of rickets and osteomalacia.
Once taking supplements, the immunoassays that are used for Vitamin D testing inaccurately measure Vitamin D2 which supplements contain. Therefore, it is a notoriously unreliable test. The only high-quality evidence for Vitamin D testing is in patients with suspected rickets or osteomalacia.
Recommendations from Public Health England to routinely supplement high-risk groups (housebound, dark skin and little sun exposure, breastfed babies <1 year and all children 1–4 years) with 400 IU (10mcg) of vitamin D/day are likely to prevent the rare cases of osteomalacia and rickets and make testing for most of the population redundant.
This project outlines how to improve vitamin D testing in your practice (see disclaimers).
You might like to create SMART goals for this project e.g. run a training session on vitamin D for clinical staff within the next month and reduce vitamin D testing by >30% over the next 3 months.
How to carry out this project
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Training
Demonstrating a gap in a clinician’s own practice is highly motivating for change and typically leads to approximately 5% change in practice. Therefore, run an education session for clinicians around which groups should have vitamin D tested:
- Osteomalacia
- Suspected osteomalacia
- Chronic widespread pain/bone pain
- Starting anti-resorptive treatment eg. bisphosphonates, denosumab
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Helpful websites
These websites may be useful to use for your educational session:
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Helpful language
Discuss useful language useful for shared decision making conversations:
Resource: Discussion
Patient: “I would like a vitamin D level to test my status.” Clinician: “There is a lot of attention on vitamin D. What have you read or heard that leads you to wonder about this?” or “I would like to understand what you are most concerned about that leads to your request.” Patient: “I’ve heard that deficiency in vitamin D can cause...” Clinician: “Oh, I can understand your concern about (name it specifically). Perhaps I can tell you more about that issue and we can then decide together whether you need a vitamin D level or not.” Clinician: Present key information about the patient’s specific concern; how we get vitamin D from sunlight or supplements; the groups at high risk of deficiency (indicating whether the patient falls in any of these), the best evidence about not testing but using supplementation.
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Patient information
This could include patient leaflets and text messaging. You might like to consult your patient participation group with the design:
Resource: Patient SMS message
“Your blood tests show your vitamin D level is slightly reduced. You do not need a prescription, but I recommend that you start taking vitamin D tablets at a daily dose of 10mcg (also labelled as 400iu) for 3 months and during the winter months. You can buy these from any pharmacy. This will boost your level, so you do not need a repeat test.”
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Computer pop-up
Consider creating a computer pop-up when vitamin D is requested which reminds staff of when it is appropriate to test.
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Study
Review the results, summarise learning, share with practice team + decide if any changes are needed to improve the process.
Decide when to re-audit again to ensure the change has lasted e.g. 6-12 months and use the Project Monitoring form to keep track.
Many practices run automatic searches at regular intervals – speak to your practice team about including this project in those searches.
Top tip
You might need to remind your team about not requesting Vitamin D tests quite a few times before everyone adopts this change.
We found it helpful to chat directly to the clinicians who kept ordering Vitamin D to change requests across the board.
How to scale this project up or down
| Please note – Use of this project requires NetworkPLUS membership. If you would like to share this project with others, please invite them to purchase their own membership—access must not be shared with non-members. |
Consider sharing your project with your PCN, Federation, ICB (England) or Cluster, Health Board (Scotland or Wales) or GP federation, Health Trust (Northern Ireland), so the learning can be shared and the project easily implemented by other practices too.
Have you completed this QIP?
Tell us a little about your project and enter your data in order to generate a certificate showing the probable cost and carbon savings and other benefits. This project may help with CQC evidence submission (see disclaimers).
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