1. Vitamin D Screening in the general ambulatory population STEVEN ZHAO PGY2 COST CONSCIOUS PROJECT MAY 2016

2. What is the evidence behind screening? Screening tests should:  Be highly sensitive  Be relatively cheap/noninvasive  Identify a condition that is relatively prevalent in the population with high morbidity/mortality  Identify a condition that is treatable

3. What is the evidence behind screening? Screening tests should:  Be highly sensitive  No clear cutoff for hypovitaminosis (20ng/mL vs 30ng/mL). No clinical definition of vitamin deficiency  Variety of commonly used assays but none are standardized  Be relatively cheap/noninvasive  Identify a condition that is relatively prevalent in the population with high morbidity/mortality  Identify a condition that is treatable

4. What is the evidence behind screening? Screening tests should:  Be highly sensitive  Be relatively cheap/noninvasive  60$ per test (labcorp), range $50-$200 1  Medicare spent >$200 million on vitamin D testing in 2011 2  Identify a condition that is relatively prevalent in the population with high morbidity/mortality  Identify a condition that is treatable 1. http://www.aafp.org/afp/2013/0415/od2.html 2. http://www.choosingwisely.org/patient- resources/vitamin-d-tests/

5. What is the evidence behind screening? Screening tests should:  Be highly sensitive  Be relatively cheap/noninvasive  Identify a condition that is relatively prevalent in the population with high morbidity/mortality  19% 1 -77% 2 prevalence in the US depending on test assay and cutoff used  Unclear what clinical impact hypovitaminosis D has  Identify a condition that is treatable 1.Taylor CL, Carriquiry AL, Bailey RL, Sempos CT, Yetley EA. Appropriateness of the probability approach with a nutrient status biomarker to assess population inadequacy: a study using vitamin D. Am J Clin Nutr. 2013; 97:72- 8. 2. Ginde AA, Liu MC, Camargo CA Jr. Demographic differences and trends of vitamin D insufficiency in the US population, 1988-2004. Arch Intern Med. 2009; 169:626-32.

6. What is the evidence behind screening? Screening tests should:  Be highly sensitive  Be relatively cheap/noninvasive  Identify a condition that is relatively prevalent in the population with high morbidity/mortality  Identify a condition that is treatable  Evidence conflicting whether vitamin D supplementation reduces risk of falls 1-2  May be associated with reduction in cancer, CVD etc but not clearly linked 1. JAMA. 2004 Apr 28;291(16):1999-2006. Effect of Vitamin D on falls: a meta-analysis. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin HB, Bazemore MG, Zee RY, Wong JB. 2. Cochrane Database Syst Rev. 2012 Sep 12;9:CD007146. doi: 10.1002/14651858.CD007146.pub3. Interventions for preventing falls in older people living in the community. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE.

9. Current UCI practice 20 EMRs (chosen in sequence, May 2016) reviewed from initial patient visit by single UCI primary care attending In all 20, vitamin D levels were checked as part of “baseline labs” without any documentation of symptoms or prior lab evidence of hypovitaminosis D.

10. Implications  Currently we are over-screening patients for vitamin D deficiency  Should either empirically treat/not test at all in general population  Caveat: in high risk patients, testing and/or treatment thresholds may be lower