Who needs a vitamin D test -Those with symptoms or those in high risk groups

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 1. 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 1. Some groups suggest limiting testing to those with a few narrowly defined symptoms 1. Some groups are testing only individuals in groups at high risk for being deficient (dark skin, obese, pregnant, etc) 1. Some groups have decided to suggest Vitamin D to all members of high risk groups 1. Some groups have decided to suggest Vitamin D for everyone 1. Turkey decided to give free vitamin D to all children --- * * Tests for Vitamin D category listing has 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 for 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.

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