Nurse Practitioner–Led Vitamin D Screening and Supplementation Program in Rural Primary Care

Published:November 17, 2021DOI:https://doi.org/10.1016/j.nurpra.2021.10.020

      Highlights

      • Vitamin D deficiency is the most prevalent micronutrient deficiency in the world, predisposing elderly patients to many chronic disease states.
      • Vitamin D deficiency can be prevented with systematic screening and supplementation in primary care.
      • This practice change added a serum 25-hydroxyvitamin D EMR prompt to an existing fasting lab order set used at Medicare annual wellness visits.
      • Substantial increases were realized in the number of patients offered vitamin D screening, the number of patients screened and supplemented because of the electronic medical record prompt.

      Abstract

      Vitamin D deficiency is the most prevalent micronutrient deficiency in the world and is associated with myriad preventable chronic illnesses. To address this problem in a rural primary care practice, an electronic medical record (EMR) prompt for serum 25-hydroxyvitamin D was added to an existing lab order set to screen vulnerable elderly patients over age 65 years for vitamin D deficiency during a Medicare Annual Wellness Visit (MAWV). The EMR prompt increased the percentage of patients screened by 90%, the number of patients screened by 1,400%, and those supplemented by 783%. These results suggest that vitamin D screening during Medicare Annual Wellness Visits provides a platform to screen and supplement vitamin D to mitigate chronic diseases associated with deficiency.

      Keywords

      American Association of Nurse Practitioners (AANP) members may receive 1.0 continuing education contact hour, approved by AANP, by reading this article and completing the online posttest and evaluation at aanp.inreachce.com.

      Background

      Vitamin D is a fat-soluble, steroid-based vitamin synthesized by the skin when an individual is exposed to sunlight and found in fortified foods, including dark, oily fishes.
      • Charoenngam N.
      • Shirvani A.
      • Holick M.
      Vitamin D for skeletal and non-skeletal health: what we should know.
      Vitamin D deficiency is defined as a serum 25-hydroxyvitamin D level <30 ng/mL and is associated with preventable adverse health sequelae.
      • Holick M.
      • Chen T.
      Vitamin D deficiency: a worldwide problem with health consequences.
      Unfortunately, vitamin D deficiency is the most common micronutrient deficiency globally,
      • O’Shea P.
      • Griffin T.
      • Brennan M.
      • Mulkerrin E.
      Covid-19: the older adult and the importance of vitamin D sufficiency.
      and approximately 1 billion individuals worldwide are vitamin D deficient.
      • Charoenngam N.
      • Holick M.
      Immunologic effects of vitamin D on human health and disease.
      Deficient vitamin D levels are associated with chronic illnesses involving the musculoskeletal, respiratory, cardiovascular, and immune systems and affect people over age 65 at a disproportionate rate.
      • Charoenngam N.
      • Holick M.
      Immunologic effects of vitamin D on human health and disease.
      In 2019, 61% of elderly patients in the United States were vitamin D deficient.
      • Sizar O.
      • Khare S.
      • Goyal A.
      • Bansal P.
      • Givler A.
      Vitamin D deficiency.
      However, vitamin D deficiency is preventable with oral supplementation, yet at present, no universal recommendations exist for systematic screening of serum vitamin D in geriatric populations.
      Individuals living in temperate climates have limited sunlight exposure during cold-weather months. Therefore, large groups of people may be vitamin D deficient during months when viral illnesses are most common.
      • Greiller C.
      • Martineau A.
      Modulation of the immune response to respiratory viruses by vitamin D.
      Vitamin D deficiency also predisposes vulnerable populations to multiple chronic disease states. Nurse practitioners (NPs) can decrease the risk and burden of disease associated with vitamin D deficiency by screening and providing appropriate supplementation. Utilizing an electronic medical record (EMR) prompt during medicare annual wellness visits (MAWV) can streamline the screening process for NPs, particularly as expanded coverage for at-risk diagnoses has resulted in full payment for annual serum 25-hydroxyvitamin D screening.
      U.S. Centers for Medicare and Medicaid Services
      Preventive screening services. 2010.
      ,
      • Scott M.
      • Gronowski A.
      Vitamin D: the more we know, the less we know.

      Available Knowledge

      Several themes emerged from the literature review and appraisal. Vitamin D deficiency is associated with increased fracture risk, low calcium absorption, and decreased bone and muscle health.
      • Wang H.
      • Chen W.
      • Li D.
      • et al.
      Vitamin D and chronic diseases.
      Vitamin D levels affect the risk for certain metabolic disorders such as hypertension, hyperlipidemia, type II diabetes.
      • Wenclewska S.
      • Szymczak-Pajor I.
      • Drzewoski J.
      • Bunk M.
      • Sliwinska A.
      Vitamin D supplementation reduces both oxidative DNA damage and insulin resistance in the elderly with metabolic disorders.
      Vitamin D adequacy minimizes cardiovascular risk
      • Holick M.
      Vitamin D deficiency.
      ; is associated with optimal immune function; and reduces risks related to upper respiratory infections (URIs), community-acquired pneumonia, and COVID-19 severity (including cytokine storm).
      • Bergman P.
      • Lindh A.
      • Bjorkman-Bergman L.
      • Lindh J.
      Vitamin D and respiratory tract infections: a systematic review and meta-analysis of randomized control trials.
      • Fantacone M.
      • Lowry M.
      • Uesugi S.
      • et al.
      The effect of a multivitamin and mineral supplement on immune function in healthy older adults: a double-blind, randomized, controlled trial.
      • Martineau A.
      • Joliffe D.
      • Hooper R.
      • et al.
      Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data.

      Musculoskeletal Health

      Vitamin D deficiency is associated with increased fracture risk, low calcium absorption, decreased bone density, and diminished muscle health. Vitamin D is a necessary nutrient in dietary calcium absorption and metabolism,
      • Holick M.
      Vitamin D deficiency.
      with deficiency resulting in musculoskeletal problems in the elderly, including brittle joints, muscle weakness, and an increased risk of falling with subsequent increased fracture risk.
      • Wang H.
      • Chen W.
      • Li D.
      • et al.
      Vitamin D and chronic diseases.
      In addition, vitamin D and calcium supplementation can preserve bone density later into the lifespan.

      Zhou, J, Luo, B, Qin, L. (2020). Fall prevention and anti-osteoporosis in osteopenia patients of 80 years of age and older: A randomized controlled study. Orthopaedic Surgery, 12(3), 890-899. http://doi:10.1111/os.12701

      Vitamin D is synthesized in the skin when individuals have adequate (20 minutes per day) sunlight exposure.
      • Holick M.
      Vitamin D deficiency.
      Moreover, vitamin D screening and supplementation guidelines quantify deficient levels (<20 ng/mL), insufficient levels (20–30 ng/mL), and adequacy (>30 ng/mL).
      • Bordelon P.
      • Ghetu M.
      • Langan R.
      Recognition and management of vitamin D deficiency.
      The 2 most significant factors for vitamin D deficiency are age and body mass index (BMI). Nearly half of the elderly patients screened for vitamin D deficiency worldwide are vitamin D deficient.
      • Muschitz C.
      • Kocijan R.
      • Stutz V.
      • et al.
      Vitamin D levels and comorbidities in ambulatory and hospitalized patients in Austria.
      Obese adults are also considered at risk for vitamin D deficiency. Because many geriatric adults in the United States have a BMI >30, their need for vitamin D screening and supplementation is 2-fold.
      • Scott M.
      • Gronowski A.
      Vitamin D: the more we know, the less we know.

      Cardiovascular Risk

      Vitamin D levels are inversely related to cardiovascular risk.
      • Holick M.
      Vitamin D deficiency.
      Patients who are vitamin D deficient and reside in seasonal climates often require supplementation to maintain therapeutic serum D levels.
      • Holick M.
      • Chen T.
      Vitamin D deficiency: a worldwide problem with health consequences.
      Adequate vitamin D levels can mitigate chronic conditions that predispose elderly patients to premature cardiovascular disease.
      • Wang H.
      • Chen W.
      • Li D.
      • et al.
      Vitamin D and chronic diseases.
      Vitamin D–deficient patients are often significantly more hypertensive,
      • Farapti F.
      • Fadilla C.
      • Yogiswara N.
      • Adriani M.
      Effects of vitamin D supplementation on 25(OH)D concentrations and blood pressure in the elderly: a systematic review and meta-analysis.
      have less favorable lipid profiles, and have higher blood sugar levels.
      • Wenclewska S.
      • Szymczak-Pajor I.
      • Drzewoski J.
      • Bunk M.
      • Sliwinska A.
      Vitamin D supplementation reduces both oxidative DNA damage and insulin resistance in the elderly with metabolic disorders.

      Respiratory Illnesses

      The available literature underscores the association of vitamin D and respiratory illnesses, including the current COVID-19 pandemic. These studies support vitamin D’s importance in preventing and treating respiratory illnesses, including viral URIs, community-acquired pneumonia, and severe COVID-19 infections.
      • Bergman P.
      • Lindh A.
      • Bjorkman-Bergman L.
      • Lindh J.
      Vitamin D and respiratory tract infections: a systematic review and meta-analysis of randomized control trials.
      • Fantacone M.
      • Lowry M.
      • Uesugi S.
      • et al.
      The effect of a multivitamin and mineral supplement on immune function in healthy older adults: a double-blind, randomized, controlled trial.
      • Martineau A.
      • Joliffe D.
      • Hooper R.
      • et al.
      Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data.
      ,
      • Shimizu Y.
      • Ito Y.
      • Yui K.
      • Egawa K.
      • Orimo H.
      Intake of 25-hydroxyvitamin D3 reduces duration and severity of upper respiratory tract infection: a randomized, double-blind, placebo-controlled, parallel-group comparison study.
      Several studies have noted lower URI rates in patients supplemented daily with vitamin D.
      • Greiller C.
      • Martineau A.
      Modulation of the immune response to respiratory viruses by vitamin D.
      ,
      • Bergman P.
      • Lindh A.
      • Bjorkman-Bergman L.
      • Lindh J.
      Vitamin D and respiratory tract infections: a systematic review and meta-analysis of randomized control trials.
      • Fantacone M.
      • Lowry M.
      • Uesugi S.
      • et al.
      The effect of a multivitamin and mineral supplement on immune function in healthy older adults: a double-blind, randomized, controlled trial.
      • Martineau A.
      • Joliffe D.
      • Hooper R.
      • et al.
      Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data.
      Vitamin D levels of ≥38 ng/mL had a 2-fold risk reduction in URI incidence, particularly in temperate climates during cold weather months.
      • Grant W.
      • Lahore H.
      • McDonnell S.
      • et al.
      Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths.
      ,
      • Sabetta J.
      • DePetrillo P.
      • Cipriani R.
      • Smardin J.
      • Burns L.
      • Landry M.
      Serum 25-hydroxyvitamin D and the incidence of acute viral respiratory tract infections in healthy adults.
      A 7% decrease in URI risk for every 10-ng incremental increase of serum vitamin D was observed in another study.
      • Gruber-Bzura B.
      Vitamin D and influenza-prevention or therapy?.
      Vitamin D deficiency increases the risk of community-acquired pneumonia (CAP) and vitamin D levels of pneumonia patients were, on average, nearly 6 ng/mL lower across almost 21,000 patients.
      • Zhou Y.
      • Liu B.
      • Qin M.
      • Liu J.
      The association between vitamin D deficiency and community-acquired pneumonia: a meta-analysis of observational studies.
      An observed correlation between vitamin D levels and the incidence and severity of COVID-19 symptoms has also been identified.
      • O’Shea P.
      • Griffin T.
      • Brennan M.
      • Mulkerrin E.
      Covid-19: the older adult and the importance of vitamin D sufficiency.
      ,
      • Kaufman H.
      • Niles J.
      • Kroll M.
      • Bi C.
      • Holick M.
      Sars-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels.
      • Liu G.
      • Hong T.
      • Yang J.
      A single large dose of vitamin D could be used as a means of coronavirus disease 2019 prevention and treatment.
      • Galmés S.
      • Serra F.
      • Palou A.
      Current state of evidence: influence of nutritional and nutrigenetic factors on immunity in the COVID-19 pandemic framework.
      Specifically, vitamin D sufficiency is associated with a lower incidence of respiratory cytokine storm, often seen in severe COVID-19 cases.
      • Brockman-Schneider R.
      • Pickles R.
      • Gern J.
      Effects of vitamin D on airway epithelial cell morphology and rhinovirus replication.
      • Daneshkhah A.
      • Agrawal V.
      • Eshein A.
      • Subramanian H.
      • Roy H.
      • Backman V.
      Evidence for possible association of vitamin D status with cytokine storm and unregulated inflammation in COVID-19 patients.
      • Hoe E.
      • Nathanielsz J.
      • Toh Z.
      • et al.
      Anti-inflammatory effects of vitamin D on human immune cells in the context of bacterial infection.
      In a Spanish case–control study, 82% of hospitalized patients had vitamin D levels <20 ng/mL.
      • Hernandez J.
      • Nan D.
      • Fernandez-Ayala M.
      • et al.
      Vitamin D status in hospitalized patients with SARS-CoV-2 infection.
      In an Asian study, patients with serum vitamin D levels >30 ng/mL had an 11% lower mortality rate than vitamin D–deficient patients.
      • Maghbooli Z.
      • Sahaian M.
      • Ebrahimi M.
      • et al.
      Vitamin D sufficiency, a serum 25-hydroxyvitamin D at least 30 ng/ml reduced risk for adverse clinical outcomes in patients with COVID-19 infection.
      Yet another study of hospitalized COVID-19 patients suggested that vitamin D adequacy decreased the need for mechanical ventilation and the mortality rate from COVID-19 at a statistically significant level (hazard ratio = 6.12; 95% confidence interval = 2.79-13.42; P < 0.001).
      • Radujkovic A.
      • Hippchen T.
      • Tiwari-Hekkler S.
      • Dreher S.
      • Boxberger M.
      • Merle U.
      Vitamin D deficiency and outcome of COVID-19 patients.

      Medicare Wellness Visits

      MAWVs are a platform for primary care providers (PCPs) to provide evidence-based preventive care to mitigate chronic disease risk in patients over age 65
      • Ganguli I.
      • Souza J.
      • McWilliams J.
      • Mehrotra A.
      Trends in the use of the Medicare annual wellness visit, 2011–2014.
      and an opportunity for PCPs to perform a thorough physical examination and a series of health maintenance screenings. Vitamin D screening is not a required component of Medicare annual wellness visits, and vitamin D screening efforts during Medicare annual wellness (MCAW) examinations have not previously been reported in the literature. Similar evidence-based practice projects adding EMR prompts for preventive screenings have been reported including hepatitis C screening,
      • MacLean C.
      • Berger C.
      • Cangiano M.
      • Ziegelman D.
      • Lidofsky S.
      Impact of electronic reminder systems on hepatitis C screening in primary care.
      aortic aneurysm screening,
      • Hye R.
      • Smith A.
      • Wong G.
      • Vansomphone S.
      • Scott R.
      • Kanter M.
      Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program.
      and osteoporosis screening.
      • Loo T.
      • Davis R.
      • Lipsitz L.
      • et al.
      Electronic medical record reminders and panel management to improve primary care for the elderly.
      ,
      • Williams S.
      • Lawrence P.
      • Miller K.
      • et al.
      A comparison of electronic and manual fracture risk assessment tools in screening elderly male US veterans at risk for osteoporosis.

      Context

      The project was implemented during a 3-month period from March 15, 2021, to June 15, 2021, in an unaffiliated, privately owned community hospital and primary care clinic located in the rural northeast. Key project stakeholders were identified and engaged throughout the development, implementation, and evaluation of the project. The project was deemed exempt by Wilmington University’s human subject review committee.
      All participants were English speaking, over age 18, and able to consent to participate in the practice change. In addition, all patients deemed vitamin D deficient or insufficient were offered supplementation uniformly. Patients could have a MAWV completed and decline serum vitamin D monitoring without influence on the health care services received in the practice.

      Intervention

      An EMR prompt was added to screen serum 25 hydroxy-vitamin D as part of a preexisting fasting lab order set given to patients during MAWVs. MAWVs are a consistent platform to systematically screen for vitamin D status in an at-risk elderly population. ICD-10 diagnoses (if applicable) linked to the vitamin D order included Z68.3X—BMI 30+, Z91.81—fall risk, M62.9—musculoskeletal disorder, and K90.9—malabsorptive syndrome. Only patients in 1 of the 4 categories, justifying the screening from an insurance standpoint, were screened. Tying the lab test to a covered diagnosis aided low-income patients who may not have been able to afford the cost of the lab test.

      Measures

      All patients aged 65 and older who consented to the screening and had a MAWV during the 90-day implementation period were included in the intervention. Descriptive statistics were used to examine the participants’ demographics, including age, gender, race, BMI, vitamin D level, and compliance with screening. In addition, data were compared pre-and post-implementation of the EMR order prompt for the serum 25 hydroxyvitamin D test. Data points were collected for 90 days before the intervention and 90 days during the intervention. Using the selected parameters, the providers systematically identify high-risk individuals and correct vitamin D deficiency.
      Using published and generally accepted values for vitamin D deficiency (<20 mg/dL), vitamin D insufficiency (21–29 mg/dL), and vitamin D sufficiency (30+ mg/dL), recommendations for supplementation schedule were formulated. If a patient was vitamin D deficient, 50,000 IU of vitamin D3 weekly was prescribed. If a patient was vitamin D insufficient, 5,000 IU of vitamin D3 daily was recommended. If a patient’s vitamin D level was sufficient, annual rescreening was recommended.
      • Bordelon P.
      • Ghetu M.
      • Langan R.
      Recognition and management of vitamin D deficiency.
      Dawson-Hughes recommended monitoring serum 25 hydroxyvitamin D 3 months after initiating supplementation.
      • Dawson-Hughes B.
      Patient education: Vitamin D deficiency (beyond the basics). 2021.
      The American College of Clinical Endocrinology, American Academy of Orthopaedic Surgeons, and the National Institutes of Health are exceptional resources for NPs to use for patient education.

      Results

      Sample Characteristics

      Pre-implementation baseline data of MCAW visits from December 14, 2020 to March 14, 2021, and implementation data from MCAW visits from March 15, 2021 to June 15, 2021 were examined. There were 125 and 149 participants pre- and post-intervention, respectively. Most patients were Caucasian, age ranged from 65 to 94 years. The average BMI of participants was >30. Diagnoses used to justify the vitamin D screening are also outlined. Demographic data for participants are reported in Table 1, Table 2, Table 3.
      Table 1Participants’ Age and Body Mass Index (BMI)
      VariableMSDnMinMax
      Age pre-intervention726.61256589
      Age post-intervention716.81496594
      BMI pre-intervention328.41251958
      BMI post-intervention318.11491773
      Table 2Gender and Race of Participants
      VariablePre-Intervention n = 125Post-Intervention n = 149
      Gender
       Male70 (56%)77 (52%)
       Female56 (44%)72 (48%)
      Race
      Caucasian121 (96%)149
      Black or Hispanic5 (4%)0 (0%)
      Table 3Diagnoses Utilized to Justify Vitamin D Screening
      VariablePre-Intervention n = 125Post-Intervention n = 149
      History of vitamin D deficiency57 (56%)0 (0%)
      Body mass index > 3045 (36%)82 (55%)
      Musculoskeletal disorder23 (18%)19 (13%)
      Risk for falls0 (0%)48 (32%)
      Data points are reflected in Tables 4 and 5 for screening, compliance, supplementation, and vitamin D levels pre-and post-intervention. As a result of the clinical practice change, the percentage of patients who received a laboratory order for vitamin D screening increased from 10% to 100%. Compliance with laboratory testing was similar with pre-and post-practice change data at 75%, with 8 and 112 patients screened, respectively, representing a 1,400% increase. Similarly, there was a 783% increase in the number of patients who received vitamin D supplementation, with 6 and 47 patients pre- and post-practice change, respectively.
      Table 4Participants’ Vitamin D Screening, Compliance, and Supplementation
      VariablePre-InterventionPost-Intervention
      Laboratory slip provided for vitamin D screening12 (10%)149 (100%)
      Compliance with vitamin D screening8 (75%)112 (75%)
      Supplementation Required6 (75%)47 (32%)
      Table 5Participants’ Vitamin D Levels
      Serum Vitamin D LevelMSDnMinMax
      Pre-intervention28.612.0681949
      Post-intervention37.017.01112797

      Discussion

      Substantial increases were realized in the percentage and number of patients offered the screening and were subsequently screened for vitamin D deficiency. In addition, more patients were determined to lack adequate vitamin D and, as a result, were supplemented. These gains were directly related to the addition of an EMR prompt for serum 25-hydroxyvitamin D to an existing fasting lab order set used at MCAW visits in elderly patients over age 65.

      Limitations

      There are 3 primary limitations of this project. First, seasonal variance in endogenous vitamin D production in patients living in temperate climates will occur. Therefore, it is important to monitor vitamin D levels during the late fall, winter, and early spring months when patients are least likely to meet sunlight exposure requirements. Second, patients who live in more tropical climates may have access to adequate sunlight all year and may not require surveillance or supplementation of vitamin D. Finally, participants were nearly all Caucasian.
      Therefore, similar projects may attempt to replicate these results in geographic areas where patients of different ethnicities are better represented.

      NP Practice Implications

      NPs are uniquely equipped to solve problems and lead quality improvement initiatives related to health promotion. Accordingly, this project provides a foundation and springboard for primary care NPs who are looking to lead preventive projects in their practices. The mitigation of the burden of chronic disease states associated with vitamin D deficiency through a prudent systematic screening and supplementation program is critical. This project provided an opportunity for NPs to show leadership ability, clinical foresight in terms of chronic disease prevention, willingness to advocate for a vulnerable subset of the population, and a platform to display the diverse skill set of doctorally prepared NPs.

      Conclusion

      Initiating a systematic vitamin D screening and supplementation program at MCAW visits allows for predictable surveillance of vitamin D status in a vulnerable elderly population. In addition, the MCAW visit provides the perfect opportunity to address preventive efforts for not only vitamin D screening but also many chronic medical conditions. Using an EMR prompt for serum 25-hydroxyvitamin D screening incorporated into an annual fasting lab order set led to significant increases in the number of patients offered the screening, the number of patients screened, the number of patients diagnosed and subsequently supplemented with vitamin D. The prevention of chronic disease states associated with vitamin D deficiency can be realized without creating an excessive burden to the healthcare provider when the EMR is appropriately utilized.

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      Biography

      Robert A. Gregor Jr., DNP, FNP-BC, is a nurse practitioner at Berwick Medical Professionals, Berwick, PA, and can be contacted at [email protected]
      Aaron M. Sebach, PhD, DNP, AGACNP-BC, FNP-BC, is an associate professor and director of graduate nursing programs, Wilmington University College of Health Professions, New Castle, DE.