Updates on Appropriateness of Care Projects

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Updates on Appropriateness of Care Projects

07-Nov-2016

I recently wrote to a number of family physicians who were identified by the Saskatchewan Disease Control Laboratory as those with high utilization rates of Vitamin D testing.

I had a number of responses which provided insight in to the reasons for ordering Vitamin D levels; others promised to reduce the use of testing. Some advised that the reasons were patient driven, where patients presented requesting Vitamin D tests based on information from naturopaths and others such as friends, relatives, and talk shows.

Please find enclosed two documents, one from BC on Vitamin D advice for patients, and the Saskatchewan Clinical Practice recommendation guidelines published in January 2016.

I have spoken to Dr. Tania Diener and asked that public education be considered provincially.

Respectfully submitted,

Dr. David McCutcheon, Vice President, Physician & Integrated Health Services

Saskatchewan Clinical Practice Recommendation For Appropriate Use of Vitamin D Testing

January 2016

General Population:

  • There is no clinical benefit to test for serum vitamin D levels in the general population.
  • Saskatchewan residents are likely at risk of low vitamin D levels from autumn to spring, however, supplementation should be recommended without a need to screen or monitor vitamin D levels. (Health Canada Dietary Reference Intakes -http://www.hc-sc.gc.ca/fn-an/nutrition/vitamin/vita-d-eng.php)

Recommendations:

  • Do not routinely measure Vitamin D in the general population who may be at risk from low dietary intake and/or low exposure to sunlight. Vitamin D supplementation is appropriate for this general population without the need to screen or monitor Vitamin D levels.

Guideline for ordering serum 25-Hydroxy Vitamin D:

Clinically Indicated Vitamin D testing:

  • Metabolic bone diseases
  • Malabsorption syndromes
  • Hypo or hypercalcemia
  • Prescribed medications that may interfere with Vitamin D metabolism such as anticonvulsants
  • Significant renal or liver disease

Health Canada Recommended Daily Intake of Vitamin D for Patients: Age group

Recommended Dietary Allowance (RDA) per day

Tolerable Upper Intake Level (UL) per day

Infants 0-6 months

400 IU (10 mcg)

1000 IU (25 mcg)

Infants 7-12 months

400 IU (10 mcg)

1500 IU (38 mcg)

Children 1-3 years

600 IU (15 mcg)

2500 IU (63 mcg)

Children 4-8 years

600 IU (15 mcg)

3000 IU (75 mcg)

Children and Adults 9 to 70 years

600 IU (15 mcg)

4000 IU (100 mcg)

Adults > 70 years

800 IU (20 mcg)

4000 IU (100 mcg)

Pregnancy & Lactation

600 IU (15 mcg)

4000 IU (100 mcg)

D Dimer Audit

In a study of patient visits to the Emergency Departments between March and June 2016,364 D Dimer tests were ordered on18,623* patients. As expected there was considerable variation in the practice of the 30 ED physicians in the study. The range of testing, as follows, was from0% by one physician to13% by one physician.

%

0%

1%

2%

3%

4%

5%

7%

8%

13%

Physician #

1**

2

11

8

3

2

1

1

1

The Mean was 2%; the Median was 4% and the Mode was 2%.

The information has been presented to the ED physicians and the audit will be repeated in three months’ time. The audit was conducted jointly by Dr. Terry Ross, Department Head of the Emergency Medicine, and Robyn Shenner from the Medicine KOT. We would like to express our thanks to the staff in the Laboratory who gathered the data for this audit.

 *This number may be understated and is under review.

**This physician ordered one D-Dimer test in 627 visits and this was rounded to zero.