Clinical Management of Low Vitamin D: A Scoping Review of Physician Practices
J. Clinical Management of Low Vitamin D: (doi: 10.20944/preprints201803.0131.v1).
Michelle Rockwell * , Vivica Kraak , Matthew Hulver , John Epling
A variety of Vitamin D Testing Opinions
- Many countries have decided that testing everyone for Vitamin D costs too much and have restricted testing
- Which is a mistake because the resulting Vitamin D deficiency problems are far more costly
- Some allow testing, but the patient has to pay for it
- US Medicare (incorrectly) only pays for 1 vitamin D test per lifetime
- Some groups suggest limiting testing to those with a few narrowly defined symptoms
- Some groups are testing only individuals in groups at high risk for being deficient (dark skin, obese, pregnant, etc)
- Some groups have decided to suggest Vitamin D to all members of high risk groups
- Some groups have decided to suggest Vitamin D for everyone
- Turkey decided to give free vitamin D to all children
- Tests for Vitamin D category listing has 141 items along with related searches
- Low cost vitamin D Blood Tests Cost to patient: ~$60 at home, ~$200 at the hospital
- VA showed increased vitamin D associated with lower health costs - Lancet May 2012
- Vitamin D deficiency of a group - 15 pcnt to 48 pcnt (depends on tester used) - Nov 2017
- Current tests are not very accurate
- Mandatory Vitamin D screening for all patients – vitamin D conference in Middle East – March 2017
- Japanese need at least 30 ng of Vitamin D, test costs are now reimbursed – Nov 2016
- France restricts Vitamin D testing to 4 health problems, paper proposes 5 more – Nov 2016
- Vitamin D test costs Obamacare pregnant woman 214 dollars (vs 6 dollars for a bottle) – Oct 2015
- Vitamin D – whom to test and whom to treat – May 2015
- Quick, free, self test of vitamin D deficiency painful tibia or sternum?
From the study
| Population-wide 25-OH-D screening recommended? | 25-OH-D testing for individuals at high risk of deficiency recommended? | Definition of "high risk" | |
| Public Health England National Osteoporosis Society, 2017 | No | Yes | Symptoms indicative of rickets, osteomalacia or symptomatic hypocalcaemia |
| U.S. Preventive Services Task Force, 2015 | Current evidence is insufficient to assess The balance of benefits and harms of screening in asymptomatic adults (I statement) | n/a | n/a |
| American Academy of Family Physicians, 2014 | Current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency (I) | No | n/a |
| Canadian Medical Association, 2012 | No | Yes | Significant renal or liver disease Osteomalacia, osteopenia or osteoporosis Malabsorptionsyndromes Hypo or hypercalcemia/ hyperphosphatemia Hypo or Hyperparathyroidism Patients on medications that affect vitamin D metabolism or absorption Unexplained increased levels of serum alkaline phosphatase Patients taking high doses of vitamin D (> 2000 IU daily) for extended periods of time (> 6 months), and who are exhibiting symptoms suggestive of vitamin D toxicosis (hypervitaminosis D) |
| U.S. Endocrine Society, 2011 | No | Yes | Rickets, osteomalacia, osteoporosis Chronic kidney disease Hepatic failure Malabsorption syndromes Certain medications African-American and Hispanic children and adults Pregnant and lactating women Older adults with history of falls or non-traumatic fracturesObese children and adults Granuloma-forming disorders Some lymphomas |
| Kidney Disease Outcomes Quality Initiative (KDOQI), 2009 | No | Yes | • Stage 3 or 4 kidney disease |
Studies of increased Vitamin D Testing
The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies recommend against population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. In order to assess patterns of physician management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and gray literature.
Thirty-eight records met inclusion criteria and were summarized in an evidence table.
Results from seven countries showed a consistent increase in vitamin D lab tests and related costs.
Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term.
Variability and controversy were pervasive in many aspects of vitamin D management, shining light on physician practices in the face of uncertainty.
Future research is needed is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations.
Download the PDF from Vitamin D Life