Changes to the frequency and appropriateness of vitamin D testing after the introduction of new Medicare criteria for rebates in Australian general practice: evidence from 1.5 million patients in the NPS Medicine Insight database
BMJ Open http://dx.doi.org/10.1136/bmjopen-2018-024797
David Gonzalez-Chica1,2, Nigel Stocks1
Australia now only pays for vitamin D tests where it is associated with a handfull of conditions
This restriction has reduced total cost of testing, but will probably end up increasing total cost of health problems due to undetected low vitamin D
Items in both categories Australia/NZ and Vitamin D Test are listed here:
- 94 X increase in Vitamin D testing in Australia (2000-2010, then they shut it down) – Dec 2019
- Australians paying for most Vitamin D tests, 40 percent deficient in winter - March 2019
- Vitamin D testing AND levels are increasing in Australia (NSW) – May 2014
- Vitamin D testing in Australia before they shut it down – 42 percent retested – 2013
- New Zealand GPs being asked for vitamin D testing and prescriptions – June 2013
- Vitamin D testing in Australia - huge increase in 11 years - July 2012
- Excessive vitamin D testing in Australia – July 2012
- Vitamin D deficiency and testing in Australia are epidemics - Aug 2011
- Australia is considering cutting vitamin D testing – March 2011
Tests for Vitamin D contains the following overview/opinion
- Fact: Many countries no longer pay for more than 1 (some not pay for even a single Vit D test)
They feel that Vit D testing is not needed except for a few conditions (Rickets, etc) Japan is an exception
- Fact: Vit D tests are not very accurate
The best lab tests have accuracies and repeatabilities of +-5 ng
Many lab tests have accuracies and repeatabilities of +- 10 ng - or worse
Vitamin D deficiency of a group - 15% to 48%
- Fact: Low-cost office/home Vit D tests are available around the world (not US as of 2018)
Low-cost 35 ng Y/N test by Nanospeed
Low-cost Vitamin D testers (about 13 dollars in quantity) – Feb 2018 Nanospeed
Quick, free, self test for deficiency
- Fact: 3 major Vit D gene problems are not noticed by Vit D tests
~ 20% of people have poor Vit D genes
Hint that Vit D not getting to cells: Vit D related diseases run in your family
Another hint - you have one of the 40 diseases which are 2X more likely if have poor genes
- Fact: A Vit D test will rarely (<1 in 1000) indicate that you are getting too much
- Opinion: If only getting a single test, wait till after supplementing with Vit D
3 months after starting a maintenance dose or 4 weeks after a loading dose
- UK considers Vitamin D tests appropriate for only 4 existing health problems, – June 2018
- Mandatory Vitamin D screening for all patients – vitamin D conference in Middle East – March 2017
- Hmm - Middle East wants ALL patients tested, Austrialia wants to reduce testing
- Japanese need at least 30 ng of Vitamin D, test costs are now reimbursed – Nov 2016
- Japan pays for all Vitamin D tests
- Australia only pays if person already has a vitamin D deficiency health problem
40% of Australians who had to pay for their own Vitamin D test
(no medical reason/justification) were found to have <20 ng of vitamin D in the winter
Note: Melborne latitude = 38 degrees = San Francisco
Objectives To assess changes in the frequency of vitamin D testing and detection of moderate/severe vitamin D deficiency (<30 nmol/L) among adults after the introduction of new Medicare Benefits Schedule (MBS) rebate criteria (November 2014), and their relationship to sociodemographic and clinical characteristics.
Design Dynamic (open) cohort study
Setting Primary care
Participants About 1.5 million ‘active’ patients aged 18+ years visiting a general practitioner and included in the National Prescribing Service Medicine Insight database.
Outcome measures The frequency of vitamin D testing (per 1000 consultations) and moderate/severe vitamin D deficiency (%) recorded between October 2013 and March 2016, stratified by the release of the new MBS criteria for rebate.
Results More patients were female (57.7%) and 30.2% were aged 60+ years. Vitamin D testing decreased 47% (from 40.3 to 21.4 tests per 1000 consultations) after the new MBS criteria, while the proportion of tests with no indication for being performed increased from 71.3% to 76.5%. The proportion of patients identified as moderate/severe vitamin D deficient among those tested increased from 5.4% to 6.5%. Practices located in high socioeconomic areas continued to have the highest rates of testing, but moderate/severe vitamin D deficiency detection remained 90% more frequent in practices from low socioeconomic areas after the rebate change. Furthermore, the frequency of individuals being tested was reduced independent of the patients’ sociodemographic or clinical condition, and the gap in the prevalence of vitamin D deficiency detection between those meeting or not meeting the criteria for being tested remained the same. Moderate/severe vitamin D deficiency detection decreased slightly among patients with hyperparathyroidism or chronic renal failure.
Conclusions Although the new criteria for rebate almost halved the frequency of vitamin D testing, it also lessened the frequency of testing among those at higher risk of deficiency, with only a small improvement in vitamin D deficiency detection.
Although the new criteria for rebate almost halved the frequency of vitamin D testing, it also
- lessened the frequency of testing among those at highest risk of deficiency,
- increased the proportion of tests with no indication for being performed, and
- resulted in only a small improvement in the detection of vitamin D deficiency.
Therefore, despite a marked reduction in healthcare (testing) costs,
the introduction of the new MBS criteria for rebate resulted in some unintended consequences: the changes
- did not improve the appropriateness of vitamin D testing,
- did not provide additional benefits for those at a higher risk of vitamin D deficiency and
- did not reduce health disparities in Australian general practice.
Further studies could explore the ongoing, non-financial, health costs of these changes and develop practice, GP and patient-centric interventions to improve the appropriateness of vitamin D testing.