Modifying Provider Vitamin D Screening Behavior in Primary Care

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Figure 1.
Weekly vitamin D test order rates for primary care, comprised of family and internal medicine (Model 1). Abbreviations: EHR, Electronic health record.
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Figure 2.
Weekly vitamin D test order rate for family medicine (Model 2). Abbreviation: EHR, Electronic health record.
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Figure 3.
Weekly vitamin D test order rate for internal medicine (Model 3). Abbreviation: EHR, Electronic health record.

Table 1.

Population Characteristics

	Pre-Interventions (Week 1–8)	Interventions (Week 9–18)	Post-Interventions (Week 19–26)
Number of encounters	175,115	224,826	187,565
Family medicine visits	63.2%	62.4%	62.3%
Internal medicine visits	36.8%	37.6%	37.7%
Visits with MD	72.5%	73.8%	73.3%
Visits with PA	13.9%	13.2%	13.0%
Visits with NP	13.5%	12.9%	13.4%
Nonpreventive visits	88.0%	87.7%	87.5%
Preventive visits	12.0%	12.3%	12.5%
Patient age (Mean ± Std)	55.2 ± 17.9	55.2 ± 17.6	55.1 ± 17.5
Female	60.7%	60.8%	60.7%
Patient race: caucasian	69.0%	69.0%	68.4%
Patient race: African American	20.0%	19.6%	19.8%

MD, medical doctor; NP, nurse practitioner; PA, physician assistant; Std, standard deviation.

Table 2.

Results: Effect of Interventions to Weekly Vitamin D Test Order Rates

	Pre-Intervention Rate	Absolute Effect (95% CI)	Relative Effect
Model 1. all primary care
Effect of both interventions	6.9%	−1.74^* (−2.31 to −1.16)	−25.0%
Post-intervention change in slope		−0.06 (−0.18 to 0.06)
Model 2. family medicine
Effect of both interventions	5.1%	−1.12^* (−1.44 to −0.81)	−21.8%
Postintervention change in slope		−0.08*† (−0.14 to −0.02)
Model 3. internal medicine
Effect of Education Memo	9.9%	−1.90^* (−3.00 to −0.80)	−19.2%
Postintervention change in slope		−0.04 (−0.26 to 0.18)
Effect of Quick Order Screen Removal		0.08 (−1.06 to 1.21)
Postintervention change in slope		−0.07 (−0.29 to 0.15)

Table 3.

Sub-Group Analysis by Specialty

	Family Medicine			Internal Medicine
Factors	Pre-Intervention Order Rate	Combined Intervention Absolute Effect	% Change^*	Pre-Intervention Order Rate	Education Memo Absolute Effect	% Change^*
Age, years
≥65	5.36	−1.18	−22%^†	8.84	−1.27	−14%
<65	5.04	−1.11	−22%	10.61	−2.35	−22%
Gender
Males	2.98	−0.91	−31%^†	7.09	−1.79	−25%
Females	6.51	−1.25	−19%	11.78	−1.94	−16%
Race
Caucasian	4.79	−1.24	−26%^†	9.87	−1.84	−19%
African American	5.18	−0.97	−19%	9.2	−2.13	−23%
Type of visit
Preventive	12.77	−3.45	−27%	26.83	−6.69	−25%
Nonpreventive	4.21	−0.77	−18%^†	7.41	−1.25	−17%
Provider type
MD	4.99	−0.79	−16%	10.70	−1.47	−14%
PA	5.83	−2.72	−47%	7.65	−3.98	−52%
NP	5.41	−1.10	−20%	7.19	−2.42	−34%

MD, medical doctor; NP, nurse practitioner; PA, physician assistant.
↵* % Change presented in this table are all statistically significant (p < 0.05).
↵† Statistically significant post-intervention slope.

Table 4.

Cost Impact Analysis (Payor Perspective, Medicare Rate)

	FM (Model 2)	IM (Model 3)
Number of visits in 2018	778,410	575,181
Estimated preintervention order rate	5.13	9.88
Estimated postintervention order rate	2.73	7.98
Impact on annualized vitamin D test orders
Estimated orders if no intervention	39,932	56,828
Estimated orders with the intervention	21,251	45,899
Estimated orders prevented thanks to the intervention	−18,682	−10,928
Impact on total cost of care
Medicare payment per vitamin D test	$35.82	$35.82
Cost savings	−$669,183.51	−$391,456.68
Total cost savings from prevented vitamin D test orders	−$1,060,640.19