Research ArticleOriginal Research

Patterns of Clinical Care Subsequent to Nonindicated Vitamin D Testing in Primary Care

Michelle S. Rockwell, YingXing Wu, Mariana Salamoun, Matthew W. Hulver and John W. Epling
The Journal of the American Board of Family Medicine July 2020, 33 (4) 569-579; DOI: https://doi.org/10.3122/jabfm.2020.04.200007

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Vitamin D-relevant services incurred in the 24 months following a nonindicated vitamin D test. An alluvial diagram showing the flow of vitamin D-relevant service utilization for 2 years following a nonindicated vitamin D test in 2015.

  • Figure 2.
    Figure 2.

    Proportion of low and normal vitamin D test results following vitamin D2 and vitamin D3 prescriptions *The highest vitamin D test result attained during the 24 months following a nonindicated index vitamin D test.

Tables

  • Table 1.

    Indicators for Vitamin D Testing

    Category of Indication*ICD-10 Text DiagnosisICD-10 Code(s)†
    Vitamin D deficiency or insufficiency, osteomalacia, ricketsRickets, activeE55.0
    Vitamin D deficiency, unspecifiedE55.9
    Sequelae of ricketsE64.3
    Adult osteomalaciaM83
    Adult osteomalacia due to malnutritionM83.3
    Disorder of bone density and structure, unspecifiedM85.9
    Disorder of bone, unspecifiedM89.9
    Osteoporosis, osteopeniaOsteoporosis with current pathological fractureM80
    Osteoporosis without current pathological fractureM81
    Pathological fracture or stress fractureStress fractureM84.3
    Pathological fractureM84.4
    Malabsorption or inflammatory bowel diseaseCrohn's disease [regional enteritis]K50
    Ulcerative colitisK51
    Celiac disease, tropical sprue, blind loop syndrome, pancreatic steatorrhea, other malabsorption due to intoleranceK90.0-K90.4
    Other intestinal malabsorptionK90.89
    Intestinal malabsorption, unspecifiedK90.9
    Postsurgical malabsorption, not elsewhere classifiedK91.2
    Parathyroid, calcium, or phosphate disorderIdiopathic hypoparathyroidismE20.0
    Hypoparathyroidism, unspecifiedE20.9
    Secondary hyperparathyroidismE21.0-E21.5
    HypocalcemiaE83.51
    HypercalcemiaE83.52
    Chronic kidney diseaseChronic kidney disease, stages 3–5; end-stage renal diseaseN18.3-18.5; N18.6

    • ↵* Indicators for vitamin D testing based on Choosing Wisely criteria.1

    • ↵† Patients with a diagnosis of any of these ICD-10 codes were excluded from the subset of patients identified as having nonindicated vitamin D testing in 2015.

    • ICD-10, International classification of diseases, tenth revision.

  • Table 2.

    Vitamin D Test Result Reference Range

    Category25(OH)D (ng/mL)*
    Low0 to 29.9
        Vitamin D deficient0 to 19.9
        Vitamin D insufficient20 to 29.9
    Normal30 to 99.9
    High>100

    • ↵* Vitamin D test result reference range based on the reference range established by Carilion Clinic and Quest Diagnostics2.

  • Table 3.

    Demographic and Clinical Characteristics of Patients Who Had Vitamin D Testing in 2015

    CharacteristicPatients Who Had Vitamin D Test with Indication (N = 7468)*Nonindicated Vitamin D Test Subset (N = 574)*
    Age (years)
        Means (range)65.7 ± 13.5 (19.8 to 101.3)56.9 ± 11.1† (19.9 to 95.3)
        18 to 29.955 (0.7%)20 (3.5%)
        30 to 39.9244 (3.3%)54 (9.4%)
        40 to 49.9658 (8.8%)104 (18.1%)‡
        50 to 59.91388 (18.6%)165 (28.7%)‡
        60 to 69.92154 (28.8%)126 (22.0%)§
        70 to 79.91884 (25.2%)68 (11.8%)‡
        80 to 89.9949 (12.7%)31 (5.4%)§
        90 to 99.9135 (1.8%)6 (1.0%)
        >1001 (0.1%)0 (0.0%)
    Sex
        Male1779 (23.8%)227 (39.5%)‡
        Female5689 (76.2%)347 (60.5%)‡
    Race/ethnicity
        White6792 (90.9%)526 (91.6%)
        Black522 (7.0%)35 (6.1%)
        Asian53 (0.7%)3 (0.5%)
        Hispanic22 (0.3%)2 (0.3%)
        Other79 (1.1%)8 (1.4%)
    BMI (kg/m2)
        Overall mean (range)30.1 ± 7.5‖ (9.9 to 74.4)30.7 ± 9.0 (17.2 to 56.8)
        <18.573 (1.9%)1 (0.3%)
        18.5 to 24.9899 (23.0%)70 (22.4%)
        25.0 to 29.91252 (32.1%)99 (31.7%)
        30.0 to 34.9873 (22.4%)71 (22.8%)
        35.0 to 39.9418 (10.7%)44 (14.8)
        >40.0388 (9.9%)27 (8.7)
    Insurer
        Medicare3564 (47.7%)98 (17.1%)†
        Medicaid108 (1.4%)12 (2.1%)
        Commercial2092 (28.0%)240 (41.8%)‡
        Self-pay1675 (22.4%)220 (38.3%)†
        Other29 (0.38%)4 (0.70%)
    Top 5 diagnoses associated with vitamin D test
    Vitamin D deficiency: 4202 (56.3%)
    Osteoporosis/osteopenia: 2276 (30.5%)
    Chronic kidney disease: 336 (4.5%)
    Malabsorption: 300 (4.0%)
    Fracture: 24 (0.3%)    		Fatigue: 274 (48%)
    Wellness exam/screening: 113 (20%)
    Pain: 90 (16%)
    Rheumatological condition: 28 (5%)
    Depression: 25 (4%)

    • ↵* Values are n (%) unless otherwise indicated.

    • ↵† P < .001.

    • ↵‡ P < .01.

    • ↵§ P < .05

    • ↵‖ n = 3904.

    • ↵ n = 312.

    • BMI, body mass index.

  • Table 4.

    Results of Initial Vitamin D Tests in Primary Care Patients in 2015

    ResultPatients Who Had Vitamin D Test with Indication (N = 7468), n (% of Indicated Tests)Nonindicated Vitamin D Test Subset (N = 574), n (% of Nonindicated Tests)
    Vitamin D deficient (0 to 19.9 ng/mL)469 (6.3%)49 (8.6%)
    Vitamin D insufficient (20 to 29.9 ng/mL)1302 (17.5%)171 (30.0%)*
    Normal vitamin D (30 to 99.9 ng/mL)5658 (75.7%)352 (61.3%)*
    High vitamin D (>100 ng/mL)39 (0.5%)2 (0.5%)
  • Table 5.

    Vitamin D Prescriptions Provided to the Subset of Patients Who Had Nonindicated Index Vitamin D Tests in 2015

    FormDoseFrequencyDurationnPrescription Category
    Ergocalciferol/vitamin D2 (n = 73)50,000 IUWeekly4 weeks2High-dose vitamin D2
    50,000 IUWeekly8 weeks35
    50,000 IUWeekly12 weeks20
    50,000 IUWeekly16 weeks9
    50,000 IUWeekly20 weeks4
    50,000 IUWeekly24 weeks2
    50,000 IUWeekly48 weeks1
    Cholecalciferol/vitamin D3 (n = 39)50,000 IUDaily2 months1High-dose vitamin D3
    50,000 IUWeekly12 weeks1
    10,000 IUDaily4 months1
    5,000 IUDaily3 months5
    5,000 IUDaily2 months1
    4,000 IUDaily3 months1
    2,000 IUDaily10 months1Moderate-dose vitamin D3
    2,000 IUDaily6 months3
    2,000 IUDaily4 months3
    2,000 IUDaily3 months4
    2,000 IUDaily2 months3
    2,000 IUDaily1 month1
    1,000 IUDaily12 months1
    1,000 IUDaily8 months1
    1,000 IUDaily6 months4
    1,000 IUDaily4 months2
    1,000 IUDaily3 months1
    400 IUDaily6 months1Low-dose vitamin D3
    400 IUDaily3 months2
    600 mg calcium + 400 IUDaily3 months2
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