Vitamin D Deficiency Treatment Patterns in Academic Urban Medical Center | Page 2

Published Online: February 19, 2014
Paulette D. Chandler, MD, MPH; Edward L. Giovannucci, MD, ScD; Michelle A. Williams, ScD; Meryl S. LeBoff, MD; David W. Bates, MD, MSc; and LeRoi S. Hicks, MD, MPH
We assessed whether race/ethnicity, age, sex, Elixhauser comorbidity score, or insurance status modified the likelihood of receiving a vitamin D prescription. In a fully adjusted model, we found no difference in prescription likelihood for blacks and whites (OR = 1.18, 95% CI, 0.88-1.58; P = .29) or Hispanics and whites (OR = 1.01, 95% CI, 0.70-1.45; P = .73). Similarly, the fully adjusted model showed no difference in prescription likelihood for females and males (OR = 1.23, 95% CI, 0.93-1.63; P = .12) (Table 4). Comorbidities did not influence likelihood of receiving a vitamin D prescription (Table 4).


Many studies have documented disparities in vitamin D deficiency prevalence.31-39 Correction of vitamin D deficiency in ambulatory care, an important strategy to reduce vitamin D deficiency disparities, is less well studied. In this large, racially and ethnically diverse cohort of primary care patients with 25OHD deficiency, 66.2% of patients did not receive a vitamin D prescription for vitamin D deficiency. Furthermore, in terms of prescriptions given, male patients received fewer prescriptions. Lastly, the rate of vitamin D prescriptions for blacks and Hispanics was significantly higher than that for whites,and white women received fewer prescriptions than black and Hispanic women. To our knowledge, this is the first examination of vitamin D prescribing for 25OHD deficiency among patients in a primary care clinic in the United States.

Given the recent IOM report, we chose the threshold of 20 ng/mL to determine appropriateness of therapy in order to be consistent with the most conservative guidelines. 27 The IOM recommends that children and adults (1-70 years) need 600 IU/day of vitamin D, whereas adults 71 years and older need 800 IU of vitamin D. In contrast to the IOM, the Endocrine Society Task Force recommends screening for vitamin D deficiency with serum 25OHD in individuals at risk for deficiency and treatment with supplements when vitamin D deficiency is identified. 29 The Task Force suggests using either vitamin D2 or vitamin D3 for the treatment of vitamin D deficiency. The Task Force guidelines state that all vitamin D-deficient adults should be treated with 50,000 IU of vitamin D2 or D3 once a week for 8 weeks or its equivalent of 6000 IU of vitamin D2 or D3 daily to achieve a 25OHD blood level above 30 ng/mL.29

In this study population, evaluation of vitamin D therapy was limited to documented vitamin D prescriptions. The overall low use of vitamin D prescriptions for vitamin D deficiency agrees with the supplement use research. There is low use of appropriate vitamin supplementation for evidence-based clinical benefits such as preconception prescribing of a multivitamin with folate for women of child-bearing age to reduce neural tube defects, as recommended by US Preventive Services Task Force (USPSTF) guidelines.40-46 Studies of vitamin D prescribing patterns in 6 southeastern VA (Department of Veterans Affairs) medical centers have documented that veterans who were tested and effectively treated had the lowest yearly inpatient costs.19 Specifically, inpatient laboratory and pharmacy costs were twice as high among vitamin D-deficient patients compared with patients not deficient in vitamin D; length of hospitalization was also longer for vitamin D-deficient patients.19 Furthermore, if patients in this cohort were taking over-the-counter vitamin D or a multivitamin, their overall 25OHD level was still low.

The consequences of chronic vitamin D deficiency— osteomalacia, osteopenia, and osteoporosis—are each associated with increased fracture risk.3 In an evaluation of community-dwelling postmenopausal women with hip fracture and without secondary osteoporosis as a cause, 50% had extreme vitamin D deficiency (25OHD <12 ng/mL).5 Thus, the USPSTF advises exercise or physical therapy and vitamin D supplementation to prevent falls in adults 65 years or older who are at increased risk for falls.47

Additionally, the risk of all-cause mortality is inversely related to 25OHD level.21-23 Low serum 25OHD at critical care initiation is associated with increased mortality and a higher rate of sepsis.9,10 Vitamin D may be associated with sepsis through its modulatory role in the inflammatory pathways of sepsis and local immune response to pathogens.12,13,48-51

Healthcare providers have a unique opportunity to diagnose and treat vitamin D deficiency. In blacks and whites, studies have associated a lack of vitamin D supplementation with lower vitamin D levels.52,53 Even among black men and women taking vitamin D supplements, the prevalence of vitamin D deficiency is greater than in whites.53,54 In a perioperative inpatient intervention program for hip fracture patients, patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive interventions such as vitamin D deficiency treatment.55 Future studies can evaluate the efficacy of outpatient computer-assisted enhancement of fracture prevention initiatives within the EMR.

The lower vitamin D treatment rates in men are in agreement with earlier studies. Prior literature suggests that vitamin D deficiency may be ignored in men unless they have underlying risk factors for poor bone health such as chronic steroid use.56-60 Vitamin D may be overprescribed in light of IOM report that suggests that patients are vitamin D replete when they have a 25OHD level greater than or equal to 20 ng/mL.27 Yet this study suggests that vitamin D deficiency is being undertreated in all patients, given that only about one-third of patients with a 25OHD level less than 20 ng/mL received some form of vitamin D prescription within 30 days. The low prescription rate confirms low treatment of vitamin D deficiency. A 2000 IOM report estimates that medication errors are among the most common medical mistakes and highlights that errors are most common when prescribing and administering medications.61 Furthermore, McGlynn and colleagues62 report that adults receive only 55% of recommended care, with no significant difference in the recommended preventive care versus the recommended acute care provided.

There are some limitations to our study. We examined patients receiving care in a multiethnic practice affiliated with a single large tertiary hospital. This practice was selected because it was representative of the most ethnically diverse primary care patient population (24.8% black, 47.7% white, 14.1% Hispanic) and it had the largest patient population, with 31 attending physicians and 2 nurse practitioners. Our findings may not be generalizable outside of similar academic settings. Interpretation of these findings is limited by the absence of information regarding the indication for testing. Determinants of the decision to test for vitamin D deficiency may influence vitamin D deficiency treatment patterns. Yet the most common indications for checking 25OHD (eg, osteoporosis) would prompt treatment of vitamin D deficiency. Another limitation relates to electronic prescribing as our primary predictor of treatment of vitamin D deficiency; we may have underestimated treatment if a significant number of patients were told to take over-the-counter supplementation. Orrico63 noted that the most common discrepancy between EMR and actual outpatient medication use is the presence of an EMR medication that is no longer being taken by the patient. They also noted that the most common patient-generated discrepancy was the omission of a multivitamin. However, the high frequency of vitamin D deficiency in this population suggests that patients are not ingesting adequate amounts of vitamin D.

Although we used comorbidities as a proxy for the intensity of relationship between patient and doctor, factors in the patient-doctor interaction likely are not represented in our model. Finally, performance measures are inherently limited in their ability to predict quality and outcomes, and measures of treatment of vitamin D deficiency have not yet been validated through large-scale implementation.

In summary, we found no difference in adjusted results by race/ethnicity or sex for vitamin D prescribing for vitamin D deficiency. Overall, there were very low rates of treatment for vitamin D deficiency in this study. Vitamin D deficiency is associated with increased fracture risk and mortality. Future work should focus on increasing vitamin D prescribing for vitamin D deficiency.

Randomized controlled trials of vitamin D supplementation in older adults are warranted to determine whether the association between hypovitaminosis D and death is causal and reversible, and whether treatment of vitamin D deficiency reduces sepsis risk.

Take-Away Points

Overall, we found low vitamin D prescribing rates for identified vitamin D deficiency. 
  • A knowledge-to-action gap exists for prompt treatment of vitamin D deficiency and contributes to chronic vitamin D deficiency. 

  • Vitamin D supplementation is a tolerable low-cost intervention with strong evidence for fracture prevention and possible reduction in mortality.

  • Physicians and other healthcare providers must integrate evidence-based practices for vitamin D supplementation into care pathways to prevent and treat vitamin D deficiency.
Author Affiliations: Brigham and Women’s Hospital, Boston, MA (PDC, MSL, DWB); Harvard Medical School (ELG); Harvard School of Public Health (MAW); University of Massachusetts - Medicine (LSH).

Funding Source: This study was funded via a grant from the National Cancer Institute (NCI U01CA138962). 

Author Disclosures: The authors (PDC, ELG, MAW, MSL, DWB, LSH) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (PDC, ELG, LSH, DWB, MSL); acquisition of data (PDC, MSL); analysis and interpretation of data (PDC, MAW, ELG, LSH, DWB, MSL); drafting of the manuscript (PDC, LSH); critical revision of the manuscript for important intellectual content (PDC, MAW, ELG, LSH, DWB, MSL); statistical analysis (PDC); provision of study materials or patients (PDC); obtaining funding (PDC); administrative, technical, or logistic support (PDC, DWB); supervision (PDC, MAW).

Address correspondence to: Paulette D. Chandler, MD, Brigham and Women’s Hospital, Phyllis Jen Center of Primary Care, Ste G, 75 Francis St, Boston, MA 02115. E-mail: pchandler@partners.org.
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