Vitamin D Screening: Is it Really Necessary?

Vitamin D is a vitamin that is mostly obtained through sun exposure, but is also obtained by taking supplements and foods we may consume on a daily basis[1]. In addition, as defined by the National Institute of Health (NIH), vitamin D “promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts.” [2] Although vitamin D is important for your bones, the problem resides in actually testing for it. According to the U.S Preventive Services Task Force, it is not recommended for physicians to test healthy patients for vitamin D because experts have yet to agree on an actual low number for vitamin D.   For instance, some believe that vitamin D deficiency is defined by a level below 20 nanograms per milliliter (ng/mL), others believe it is below 50 ng/mL. [3] Furthermore, not only is there disagreement on the appropriate level, but testing for vitamin D may lead to unnecessary treatments that can be harmful costly.  For instance, according to the Choosing Wisely initiative, the Medicare program spent a total of $224 million on vitamin D testing for seniors in 2011.[4]

When we go for our yearly physical exams, our primary care physicians typically order a panel of blood tests. These tests mainly include a CBC, CMP, TSH, lipid panel, HbA1C, and often it also includes a vitamin D (25-hydroxyvitamin D) test.  From the patient’s perspective, we are normally not aware of the individual tests included in the panel. From a clinician’s perspective, they order these tests because they are the standard of care and want to make sure they are covering all bases.  Sometimes, clinicians may not be fully aware of what the individual patient’s insurance coverage is for certain tests.   For instance, a very caring doctor I use to work for, use to order vitamin D tests on every single patient as part of their physical to make sure the patient had good vitamin D levels.  Yet, I was the one receiving angry calls from patients demanding for me to explain their high bill for that one blood test (Vit-D) since their insurance was refusing to pay. At that point, they would ask me, was this test necessary? Why did the doctor order it, if I feel fine?  This issue was escalated and later discussed at one of our administration meetings.  Going forward, the chief of internal medicine reminded the clinicians to be more conscientious when ordering vitamin D screenings and to make sure it was not buried in their annual physical testing panel in the EHR system. Strategies such as the one aforementioned have been successful in preventing physicians from ordering vitamin D tests as part of the physical tests. In an attempt to reduce the amount of people being tested for vitamin D in Alberta, Canada, they made it a requirement to check off one of the diagnosis specifically for vitamin D; metabolic bone disease, abnormal blood calcium levels, nutrient absorption problems such as celiac disease, chronic kidney disease, and liver disease[5]. This small change resulted in dropping testing rates by approximately 92% that saved taxpayers $4 million dollars![6

Since testing for vitamin D level has very little benefit and raises the costs of health care tremendously; it is considered low-value care. Aim I of Virginia Center for Health Innovation’s Health Value Dashboard is to reduce low-value care and “Avoid Vitamin D screening” is one of the indicators under that aim. [7] Change starts with conversations between patients and clinicians.  Change is also necessary at the system level and in payment reforms.  Unless you have osteoporosis, inflammatory bowel disease, celiac disease, kidney disease, liver disease pancreatic or any other diseases that affect your body’s capability to use vitamin D you could avoid a bill or merely unnecessary treatments by opting out of testing your vitamin D levels. In addition, you can also make sure to get enough sunlight and ensure your daily diet acquires foods rich in vitamin D such as fortified milk, orange juice, fish and eggs.[8]

References:

[1] Vitamin D Council. (n.d.). What is vitamin D? Retrieved June 2, 2018, from https://www.vitamindcouncil.org/about-vitamin-d/what-is-vitamin-d/

[2]NIH. (2018, March 02). Office of Dietary Supplements – Vitamin D. Retrieved June 2, 2018, from https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

[3] Choosing Wisely. (2014, February). Vitamin D Tests. Retrieved June 4, 2018, from http://www.choosingwisely.org/patient-resources/vitamin-d-tests/

[4] Choosing Wisely. (2014, February). Vitamin D Tests. Retrieved June 4, 2018, from http://www.choosingwisely.org/patient-resources/vitamin-d-tests/

[5] Ansley, D. (2016, May). Do You Need a Vitamin D Test? Retrieved June 5, 2018, from https://www.consumerreports.org/health/do-you-need-a-vitamin-d-test/

[6] Ansley, D. (2016, May). Do You Need a Vitamin D Test? Retrieved June 5, 2018, from https://www.consumerreports.org/health/do-you-need-a-vitamin-d-test/

[7] Virginia Center for Health Innovation. (2017). About the Dashboard. Retrieved June 4, 2018, from http://www.vahealthinnovation.org/virginia-health-value-dashboard/

[8] Ansley, D. (2016, May). Do You Need a Vitamin D Test? Retrieved June 5, 2018, from https://www.consumerreports.org/health/do-you-need-a-vitamin-d-test/