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.
1
Vitamin D deficiency is defined as a serum 25-hydroxyvitamin D level <30 ng/mL and is associated with preventable adverse health sequelae.2
Unfortunately, vitamin D deficiency is the most common micronutrient deficiency globally,3
and approximately 1 billion individuals worldwide are vitamin D deficient.4
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.
4
In 2019, 61% of elderly patients in the United States were vitamin D deficient.5
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.
6
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.7
,8
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.
9
Vitamin D levels affect the risk for certain metabolic disorders such as hypertension, hyperlipidemia, type II diabetes.10
Vitamin D adequacy minimizes cardiovascular risk11
; 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).12
, - 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.
PLoS ONE. 2013; 8e65835https://doi.org/10.1371/journal.pone.0065835
13
, 14
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,
11
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.9
In addition, vitamin D and calcium supplementation can preserve bone density later into the lifespan.15
Vitamin D is synthesized in the skin when individuals have adequate (20 minutes per day) sunlight exposure.11
Moreover, vitamin D screening and supplementation guidelines quantify deficient levels (<20 ng/mL), insufficient levels (20–30 ng/mL), and adequacy (>30 ng/mL).16
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.17
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.8
Cardiovascular Risk
Vitamin D levels are inversely related to cardiovascular risk.
11
Patients who are vitamin D deficient and reside in seasonal climates often require supplementation to maintain therapeutic serum D levels.2
Adequate vitamin D levels can mitigate chronic conditions that predispose elderly patients to premature cardiovascular disease.9
Vitamin D–deficient patients are often significantly more hypertensive,18
have less favorable lipid profiles, and have higher blood sugar levels.10
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.
12
, - 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.
PLoS ONE. 2013; 8e65835https://doi.org/10.1371/journal.pone.0065835
13
, 14
,19
Several studies have noted lower URI rates in patients supplemented daily with vitamin D.6
,12
, - 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.
PLoS ONE. 2013; 8e65835https://doi.org/10.1371/journal.pone.0065835
13
, 14
Vitamin D levels of ≥38 ng/mL had a 2-fold risk reduction in URI incidence, particularly in temperate climates during cold weather months.20
,21
A 7% decrease in URI risk for every 10-ng incremental increase of serum vitamin D was observed in another study.22
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.23
An observed correlation between vitamin D levels and the incidence and severity of COVID-19 symptoms has also been identified.3
,24
, - Kaufman H.
- Niles J.
- Kroll M.
- Bi C.
- Holick M.
Sars-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels.
PLoS ONE. 2020; 15e0239252https://doi.org/10.1371/journal.pone.0239252
25
, 26
Specifically, vitamin D sufficiency is associated with a lower incidence of respiratory cytokine storm, often seen in severe COVID-19 cases.27
, 28
, 29
In a Spanish case–control study, 82% of hospitalized patients had vitamin D levels <20 ng/mL.30
In an Asian study, patients with serum vitamin D levels >30 ng/mL had an 11% lower mortality rate than vitamin D–deficient patients.31
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).- 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.
PLoS ONE. 2020; 15e0239799https://doi.org/10.1371/journal.pone.0239799
32
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
33
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,34
aortic aneurysm screening,35
and osteoporosis screening.36
,37
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.
16
Dawson-Hughes recommended monitoring serum 25 hydroxyvitamin D 3 months after initiating supplementation.38
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)
| Variable | M | SD | n | Min | Max |
|---|---|---|---|---|---|
| Age pre-intervention | 72 | 6.6 | 125 | 65 | 89 |
| Age post-intervention | 71 | 6.8 | 149 | 65 | 94 |
| BMI pre-intervention | 32 | 8.4 | 125 | 19 | 58 |
| BMI post-intervention | 31 | 8.1 | 149 | 17 | 73 |
Table 2Gender and Race of Participants
| Variable | Pre-Intervention n = 125 | Post-Intervention n = 149 |
|---|---|---|
| Gender | ||
| Male | 70 (56%) | 77 (52%) |
| Female | 56 (44%) | 72 (48%) |
| Race | ||
| Caucasian | 121 (96%) | 149 |
| Black or Hispanic | 5 (4%) | 0 (0%) |
Table 3Diagnoses Utilized to Justify Vitamin D Screening
| Variable | Pre-Intervention n = 125 | Post-Intervention n = 149 |
|---|---|---|
| History of vitamin D deficiency | 57 (56%) | 0 (0%) |
| Body mass index > 30 | 45 (36%) | 82 (55%) |
| Musculoskeletal disorder | 23 (18%) | 19 (13%) |
| Risk for falls | 0 (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
| Variable | Pre-Intervention | Post-Intervention |
|---|---|---|
| Laboratory slip provided for vitamin D screening | 12 (10%) | 149 (100%) |
| Compliance with vitamin D screening | 8 (75%) | 112 (75%) |
| Supplementation Required | 6 (75%) | 47 (32%) |
Table 5Participants’ Vitamin D Levels
| Serum Vitamin D Level | M | SD | n | Min | Max |
|---|---|---|---|---|---|
| Pre-intervention | 28.6 | 12.06 | 8 | 19 | 49 |
| Post-intervention | 37.0 | 17.01 | 112 | 7 | 97 |
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.
References
- Vitamin D for skeletal and non-skeletal health: what we should know.J Clin Orthoped Trauma. 2019; 10: 1082-1093https://doi.org/10.1016/j.jcot.2019.07.004
- Vitamin D deficiency: a worldwide problem with health consequences.Am J Clin Nutr. 2008; 87: 1080S-1086S
- Covid-19: the older adult and the importance of vitamin D sufficiency.J Nutr Sci. 2020; 9: 1-5http://doi:10.1017/jns.2020.36
- Immunologic effects of vitamin D on human health and disease.Nutrients. 2020; 12: 2097-2125http://doi:10.3390/nu12072097
- Vitamin D deficiency.StatPearls. 2021;
- Modulation of the immune response to respiratory viruses by vitamin D.Nutrients. 2015; 7: 4240-4270
- Preventive screening services. 2010.
- Vitamin D: the more we know, the less we know.Clin Chem. 2015; 61: 462-465https://doi.org/10.1373/clinchem.2014.222521
- Vitamin D and chronic diseases.Aging Disease. 2017; 8: 346-353https://doi.org/10.14336/AD.2016.1021
- Vitamin D supplementation reduces both oxidative DNA damage and insulin resistance in the elderly with metabolic disorders.Int J Mol Sci. 2019; 20: 2891https://doi.org/10.3390/ijms20122891
- Vitamin D deficiency.New Engl J Med. 2007; 357: 266-281http://doi:10.1056/NEJMra070553
- Vitamin D and respiratory tract infections: a systematic review and meta-analysis of randomized control trials.PLoS ONE. 2013; 8e65835https://doi.org/10.1371/journal.pone.0065835
- The effect of a multivitamin and mineral supplement on immune function in healthy older adults: a double-blind, randomized, controlled trial.Nutrients. 2020; 12: 2447-2469https://doi.org/10.3390/nu12082447
- Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data.BMJ. 2017; 356: i65-i83https://doi.org/10.1136/bmj.i6583
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
- Recognition and management of vitamin D deficiency.Am Fam Physician. 2009; 80: 841-846
- Vitamin D levels and comorbidities in ambulatory and hospitalized patients in Austria.Central Eur J Med. 2015; 127: 675-684http://doi:10.1007/s00508-015-0824-5
- Effects of vitamin D supplementation on 25(OH)D concentrations and blood pressure in the elderly: a systematic review and meta-analysis.F1000 Res. 2020; 9: 633https://doi.org/10.12688/f1000research.24623.3
- Intake of 25-hydroxyvitamin D3 reduces duration and severity of upper respiratory tract infection: a randomized, double-blind, placebo-controlled, parallel-group comparison study.J Nutr Health Aging. 2018; 22: 291-500https://doi.org/10.1007/s12603-017-0952-x
- Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths.Nutrients. 2020; 12: 988-1007https://doi.org/10.3390/nu12040988
- Serum 25-hydroxyvitamin D and the incidence of acute viral respiratory tract infections in healthy adults.PLoS ONE. 2010; 5e11088http://doi:10.1371/journal.pone0011088
- Vitamin D and influenza-prevention or therapy?.Int J Mol Sci. 2018; 19: 2419-2444https://doi.org/10.3390/ijms19082419
- The association between vitamin D deficiency and community-acquired pneumonia: a meta-analysis of observational studies.Medicine. 2019; 98e17252http://doi:10.1097/MD.0000000000017252
- Sars-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels.PLoS ONE. 2020; 15e0239252https://doi.org/10.1371/journal.pone.0239252
- A single large dose of vitamin D could be used as a means of coronavirus disease 2019 prevention and treatment.Drug Design Dev Ther. 2020; 14: 3429-3434https://doi.org/10.2147/DDDT.5271754
- Current state of evidence: influence of nutritional and nutrigenetic factors on immunity in the COVID-19 pandemic framework.Nutrients. 2020; 12: 2738-2771http://doi:10.3390/nu12092738
- Effects of vitamin D on airway epithelial cell morphology and rhinovirus replication.PLoS ONE. 2014; 9e86755http://doi:10.1371/journal.pone.0086755
- Evidence for possible association of vitamin D status with cytokine storm and unregulated inflammation in COVID-19 patients.Aging Clin Exp Res. 2020; 32: 2141-2158https://doi.org/10.1007/s40520-020-01677-y
- Anti-inflammatory effects of vitamin D on human immune cells in the context of bacterial infection.Nutrients. 2016; 8: 806-820https://doi.org/10.3390/nu8120806
- Vitamin D status in hospitalized patients with SARS-CoV-2 infection.J Clin Endocrinol Metab. 2020; 106: e1343-e1353https://doi.org/10.1210/clinem/dgaa733
- 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.PLoS ONE. 2020; 15e0239799https://doi.org/10.1371/journal.pone.0239799
- Vitamin D deficiency and outcome of COVID-19 patients.Nutrients. 2020; 12: 2757-2771http://doi:10.3390/nu12092757
- Trends in the use of the Medicare annual wellness visit, 2011–2014.JAMA. 2017; 317: 2233-2235http://doi:10.1001/jama.2017.4342
- Impact of electronic reminder systems on hepatitis C screening in primary care.J Viral Hepatol. 2018; 25: 939-944https://doi.org/10.1111/jvh.12885
- Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program.J Vasc Surg. 2014; 59: 1535-1543https://doi.org/10.1016/j-jvs.2013.12.016
- Electronic medical record reminders and panel management to improve primary care for the elderly.JAMA. 2011; 171: 1552-1558
- A comparison of electronic and manual fracture risk assessment tools in screening elderly male US veterans at risk for osteoporosis.Osteoporos Int. 2017; 28: 3107-3111https://doi.org/10.1007/s00198-017-4172-3
- Patient education: Vitamin D deficiency (beyond the basics). 2021.
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.
Article info
Publication history
Published online: November 17, 2021
Footnotes
In compliance with standard ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
