Reducing 25-Hydroxyvitamin D Testing in a Large, Urban Safety Net System

Hyung J. Cho, Nessreen Mestari, Sigal Israilov, Da Wi Shin, Komal Chandra, Daniel Alaiev, Joseph Talledo, Surafel Tsega, Mariely Garcia, Milana Zaurova, Peter Alarcon Manchego, Mona Krouss

Research output: Contribution to journalArticlepeer-review


Background: 25-Hydroxyvitamin D testing is increasingdespite national guidelines and Choosing Wisely recommendations against routine screening. Overuse can lead to misdiagnosis and unnecessary downstream testing and treatment. Repeat testing within 3 months is a unique area of overuse. Objective: To reduce 25-hydroxyvitamin D testing in a large safety net system comprising 11 hospitals and 70 ambulatory centers. Design: This was a quality improvement initiative with a quasi-experimental interrupted time series design with segmented regression. Participants: All patients in the inpatient and outpatient settings with at least one order for 25-hydroxyvitamin D were included in the analysis. Interventions: An electronic health record clinical decision support tool was designed for inpatient and outpatient orders and involved two components: a mandatory prompt requiring appropriate indications and a best practice advisory (BPA) focused on repeat testing within 3 months. Main Measures: The pre-intervention period (6/17/2020–6/13/2021) was compared to the post-intervention period (6/14/2021–8/28/2022) for total 25-hydroxyvitamin D testing, as well as 3-month repeat testing. Hospital and clinic variation in testing was assessed. Additionally, best practice advisory action rates were analyzed, separated by clinician type and specialty. Key Results: There were 44% and 46% reductions in inpatient and outpatient orders, respectively (p < 0.001). Inpatient and outpatient 3-month repeat testing decreased by 61% and 48%, respectively (p < 0.001). The best practice advisory true accept rate was 13%. Conclusion: This initiative successfully reduced 25-hydroxyvitamin D testing through the use of mandatory appropriate indications and a best practice advisory focusing on a unique area of overuse: the repeat testing within a 3-month interval. There was wide variation among hospitals and clinics and variation among clinician types and specialties regarding actions to the best practice advisory.

Original languageEnglish
Pages (from-to)2326-2332
Number of pages7
JournalJournal of General Internal Medicine
Issue number10
StatePublished - Aug 2023


  • choosing wisely
  • overutilization
  • quality improvement
  • value-based care
  • vitamin D


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