Effectiveness of professional and patient-oriented strategies in reducing vitamin D and B12 test ordering in primary care: a cluster randomised intervention study

Abstract

Background: Vitamin tests are increasingly ordered by GPs, but a clinical and evidence-based indication is often lacking. Harnessing technology (that is, decision support tools and redesigning request forms) have been shown to reduce vitamin requests.

Aim: To investigate whether the number of vitamin tests may be reduced by providing a multi-level intervention programme based on training, monitoring, and feedback.

Design & setting: This was a cluster randomised intervention study performed in 26 primary care health centres (>195 000 patients) in the Netherlands. The relative reduction in ordered vitamin D and B12 tests was determined after introduction of two de-implementation strategies (1 May 2017 to 30 April 2018).

Method: Health centres randomised to de-implementation strategy 1 received education and benchmarking of their own vitamin test ordering behaviour every 3 months. Health centres in de-implementation strategy 2 received the same education and benchmarking, but supplemented with educational material for patients.

Results: The number of vitamin D tests decreased by 23% compared to the 1-year pre-intervention period (1 May 2016 to 30 April 2017). For vitamin B12 tests an overall reduction of 20% was found. Provision of patient educational information showed additional value over training and benchmarking of GPs alone for vitamin D test ordering (10% extra reduction, odds ratio [OR] 0.88, 95% confidence interval [CI] = 0.83 to 0.92), but not for vitamin B12 ordering (4% extra reduction, OR 0.96, 95% CI = 0.91 to 1.02). Nationwide, this would result in over €3 200 000 in savings on healthcare expenditure a year.

Conclusion: A structured intervention programme, including training and benchmarking of GPs regarding their diagnostic test ordering, resulted in a significant reduction in ordered vitamin tests. Additional information provision to patients resulted in a small but still relevant additional reduction. If implemented on a national level, a substantial cost saving could be achieved.

Keywords: Netherlands; diagnostic tests, routine; overdiagnosis; primary care; vitamin B12; vitamin D; vitamins.

Figure 1.. Flow diagram of the study and its participating health centres

Figure 2.. Number of ordered vitamin tests in pre-intervention period (in quartiles) related to reduction in number of ordered tests during intervention period. pts = patients.