Improving vitamin D testing and supplementation in children with newly diagnosed cancer: A quality improvement initiative at Rady Children's Hospital San Diego

Abstract

Background: Vitamin D deficiency and insufficiency have been associated with poorer health outcomes. Children with cancer are at high risk for vitamin D deficiency and insufficiency. At our institution, we identified high variability in vitamin D testing and supplementation in this population. Of those tested, 65% were vitamin D deficient/insufficient. We conducted a quality improvement (QI) initiative with aim to improve vitamin D testing and supplementation among children aged 2-18 years with newly diagnosed cancer to ≥80% over 6 months.

Methods: An inter-professional team reviewed baseline data, then developed and implemented interventions using Plan-Do-Study-Act (PDSA) cycles. Barriers were identified using QI tools, including lack of automated triggers for testing and inconsistent supplementation criteria and follow-up testing post supplementation. Interventions included an institutional vitamin D guideline, clinical decision-making tree for vitamin D deficiency, insufficiency and sufficiency, electronic medical record triggers, and automated testing options.

Results: Baseline: N = 26 patients, four (15%) had baseline vitamin D testing; two (8%) received appropriate supplementation. Postintervention: N = 33 patients; 32 (97%) had baseline vitamin D testing; 33 (100%) received appropriate supplementation and completed follow-up testing timely (6-8 weeks post supplementation). Change was sustained over 24 months.

Conclusions: We achieved and sustained our aim for vitamin D testing and supplementation in children with newly diagnosed cancer through inter-professional collaboration of hematology/oncology, endocrinology, hospital medicine, pharmacy, nursing, and information technology. Future PDSA cycles will address patient compliance with vitamin D supplementation and impact on patients' vitamin D levels.

Keywords: clinical guidelines; pediatric cancer; quality improvement; vitamin D deficiency; vitamin D supplementation.

FIGURE 1

Ishikawa diagram.

FIGURE 2

Key driver diagram.

FIGURE 3

Decision-Making Tree.

FIGURE 4

Best Practice Alert (BPA).

FIGURE 5

Vitamin D testing rates. P-chart with vitamin D testing and annotated improvement interventions in orange. Desired direction of change is noted in bold green arrow. GD Guideline development; E, Education; DT, Decision making tree; BPA, Best Practice Alert; CL, centerline; LCL, lower control limit; UCL, upper control limit. Baseline phase= GD and DT development; Intervention phase = E, DT implementation, Electronic Medical Record (EMR) triggers (BPA). Baseline phase start date: November 1, 2015; intervention phase start date: February 1, 2016, interventions were launched at the same time in February, 2016; sustainability phase start date: July 1, 2016.

FIGURE 6

Vitamin D supplementation and follow-up post-supplementation rates. P-chart with vitamin D supplementation. Desired direction of change is noted in bold green arrow. E, Education; DT, Decision making tree; BPA, Best Practice Alert; CL, centerline; LCL, lower control limit; UCL, upper control limit. Intervention phase = E, DT implementation, Electronic Medical Record (EMR) triggers (BPA). Intervention phase start date: February 1, 2016, interventions were launched at the same time in February, 2016; sustainability phase start date: July 1, 2016.