Decrease in unnecessary vitamin D testing using clinical decision support tools: making it harder to do the wrong thing.

Abstract

To evaluate the impact of clinical decision support (CDS) tools on rates of vitamin D testing. Screening for vitamin D deficiency has increased in recent years, spurred by studies suggesting vitamin D's clinical benefits. Such screening, however, is often unsupported by evidence and can incur unnecessary costs. We evaluated how rates of vitamin D screening changed after we implemented 3 CDS tools in the electronic health record (EHR) of a large health plan: (1) a new vitamin D screening guideline, (2) an alert that requires clinician acknowledgement of current guidelines to continue ordering the test (a "hard stop"), and (3) a modification of laboratory ordering preference lists that eliminates shortcuts. We assessed rates of overall vitamin D screening and appropriate vitamin D screening 6 months pre- and post-intervention. Vitamin D screening rates decreased from 74.0 tests to 24.2 tests per 1000 members ( P  < .0001). The proportion of appropriate vitamin D screening tests increased from 56.2% to 69.7% ( P  < .0001), and the proportion of inappropriate screening tests decreased from 43.8% pre-implementation to 30.3% post-implementation ( P  < .0001). To our knowledge, this is the first demonstration of how CDS can reduce rates of inappropriate vitamin D screening. We used 3 straightforward, inexpensive, and replicable CDS approaches. We know of no previous research on the impact of removing options from a preference list. Similar approaches could be used to reduce unnecessary care and decrease costs without reducing quality of care.