Health, financial and environmental impacts of unnecessary vitamin D testing: a triple bottom line assessment adapted for healthcare

Abstract

Objective: To undertake an assessment of the health, financial and environmental impacts of a well-recognised example of low-value care; inappropriate vitamin D testing.

Design: Combination of systematic literature search, analysis of routinely collected healthcare data and environmental analysis.

Setting: Australian healthcare system.

Participants: Population of Australia.

Outcome measures: We took a sustainability approach, measuring the health, financial and environmental impacts of a specific healthcare activity. Unnecessary vitamin D testing rates were estimated from best available published literature; by definition, these provide no gain in health outcomes (in contrast to appropriate/necessary tests). Australian population-based test numbers and healthcare costs were obtained from Medicare for vitamin D pathology services. Carbon emissions in kg CO₂e were estimated using data from our previous study of the carbon footprint of common pathology tests. We distinguished between tests ordered as the primary test and those ordered as an add-on to other tests, as many may be done in conjunction with other tests. We conducted base case (8% being the primary reason for the blood test) and sensitivity (12% primary test) analyses.

Results: There were a total of 4 457 657 Medicare-funded vitamin D tests in 2020, on average one test for every six Australians, an 11.8% increase from the mean 2018-2019 total. From our literature review, 76.5% of Australia's vitamin D tests provide no net health benefit, equating to 3 410 108 unnecessary tests in 2020. Total costs of unnecessary tests to Medicare amounted to >$A87 000 000. The 2020 carbon footprint of unnecessary vitamin D tests was 28 576 kg (base case) and 42 012 kg (sensitivity) CO₂e, equivalent to driving ~160 000-230 000 km in a standard passenger car.

Conclusions: Unnecessary vitamin D testing contributes to avoidable CO₂e emissions and healthcare costs. While the footprint of this example is relatively small, the potential to realise environmental cobenefits by reducing low-value care more broadly is significant.

Keywords: pathology; public health; quality in health care.

Figure 1

Australia’s vitamin D monthly* and cumulative test numbers in 2020 compared with 2018/2019 averages. (*For more details, please view online supplemental figure 2, showing Australia’s monthly vitamin D test rates.)