An article in the January issue of CLN explains why vitamin D tests can be challenging for clinicians to get right. “In our institution, we found that 66% of the 1,25 dihydroxyvitamin D tests were ordered in error, and that in these cases, 25-OH vitamin D was the intended test,” explained Jane Dickerson, PhD, DABCC, and Michael Astion, MD, PhD, who co-authored a Patient Safety Focus article on the subject.
“As laboratorians know, 25-OH vitamin D is most useful in nutritional assessment, primarily due to its longer half-life of approximately 3 weeks. 25-OH vitamin D is elevated with vitamin D intoxication and decreased with malabsorption, nutritional deficiency, and in liver disease. Conversely, the circulating half-life of 1,25 dihydroxyvitamin D is relatively short (4–6 hours), limiting utility for overall vitamin D assessment,” they explained. However, the 1,25 dihydroxyvitamin D test can be useful for diagnosis of renal dysfunction, in conjunction with parathyroid hormone. “It is elevated in sarcoidosis and primary hyperparathyroidism and decreased in renal failure and hypoparathyroidism,” wrote Dickerson and Astion.
The authors went on to describe a variety of gentle, medium, and strong tools they used to encourage clinicians to order the correct test when evaluating patients. Gentle tools included posting guidelines on requisitions and computerized reminders on utilization guidelines, medium tools incorporated utilization report cards and changes to manual requisitions or computerized physician order entry, and strong tools included utilization report cards with peer or leadership review, privileging, sendouts formulary, a requirement for high-level approval, and a rules requirement.
“While IT solutions often seem like an attractive fix for utilization management problems, the interventions require fitting within the confines and culture of your particular institution, and there should be a process in place to measure and check success,” the authors wrote. “Many times, interventions require a bit of tweaking to achieve that perfect fit.”
Pick up the January issue of CLN to read more about approaches to encouraging use of the appropriate tests.