Tai Felicia, Chin-Yee Ian, Gob Alan, Bhayana Vipin, Rutledge Angela
Department of Pathology and Laboratory Medicine, Western University, London, Ontario, Canada.
Department of Pathology and Laboratory Medicine, London Health Sciences Centre and St. Joseph's Health Care London, London, Ontario, Canada.
BMJ Open Qual. 2020 Feb;9(1). doi: 10.1136/bmjoq-2020-000929.
Testing of 25-hydroxy (25-OH) vitamin D serum levels has increased drastically in recent years and much of it is considered inappropriate based on current guidelines.
In consultation with our physician groups (experts and frequent orderers), we modified existing guidelines and implemented a rational policy for 25-OH vitamin D testing and 1,25 dihydroxy (1,25 di-OH) vitamin D testing at a tertiary care centre. A computer decision support tool requiring selection of one of five acceptable testing indications was created for each test as part of a computerised physician order entry system.
As a result of our intervention, we observed a 27% decrease in the average monthly test volume for 25-OH vitamin D from 504±62 (mean±SD) tests per month to 370±33 (p<0.001). 1,25 di-OH vitamin D testing decreased 58% from 71±18 to 30±10 (p<0.001). The departments ordering the tests were similar during the preintervention and postintervention periods, and further audits, patient chart reviews and individualised physician feedback were required to ensure appropriate ordering of 1,25 di-OH vitamin D. The most common ordering reasons selected were malabsorption/dietary concerns (46%) for 25-OH vitamin D and renal failure (42%) for 1,25 di-OH vitamin D.
Limitations of our computer decision support tool include a dependence on an honour system in selecting the testing indication and an inability to limit ordering frequency. Periodic monitoring of test volumes will be required to ensure adherence to guidelines. Despite these limitations, we have improved appropriate utilisation of these tests and reduced costs by approximately $C60 375 per year.
近年来，25-羟基（25-OH）维生素D血清水平检测急剧增加，根据当前指南，其中大部分被认为是不恰当的。
我们与医师团队（专家和频繁开单者）协商，修改了现有指南，并在一家三级医疗中心实施了一项关于25-OH维生素D检测和1,25-二羟基（1,25-二-OH）维生素D检测的合理政策。作为计算机化医师医嘱录入系统的一部分，为每项检测创建了一个计算机决策支持工具，要求从五个可接受的检测指征中选择一个。
由于我们的干预，我们观察到25-OH维生素D的平均每月检测量下降了27%，从每月504±62（均值±标准差）次检测降至370±33次（p<0.001）。1,25-二-OH维生素D检测从71±18降至30±10，下降了58%（p<0.001）。在干预前和干预后期间，开具检测医嘱的科室相似，需要进一步审计、查看患者病历以及提供个性化医师反馈，以确保1,25-二-OH维生素D检测医嘱的合理性。25-OH维生素D检测最常见的开具原因是吸收不良/饮食问题（46%），1,25-二-OH维生素D检测最常见的开具原因是肾衰竭（42%）。
我们的计算机决策支持工具的局限性包括在选择检测指征时依赖诚信制度，以及无法限制开单频率。需要定期监测检测量，以确保遵守指南。尽管有这些局限性，但我们已经改善了这些检测的合理使用，并每年降低成本约60375加元。
