Vitamin D testing: new targeted guidelines stem the overtesting tide

Bilinski and Boyages have previously reported that the frequency of vitamin D testing had risen dramatically in Australia between 2000 and 2010.1,2 Further, testing did not translate to improved health outcomes.3 Since that report,1 Medicare Benefits Schedule (MBS) expenditure on vitamin D testing rose from $109.0 million in the 2009–10 financial year to $151.1 million in 2012–13, falling slightly in 2013–14 to $143.1 million.

An MBS review for vitamin D testing in 2014 recommended targeted testing for high-risk groups only, and against population screening.3 High-risk patients include those with osteoporosis, osteomalacia, disorders of calcium and parathyroid hormone, malabsorption, chronic renal disease, patients with darker pigmented skin or reduced sun exposure, those under 16 years of age and patients taking drugs known to reduce vitamin D levels. Five new Medicare item numbers (66833, 66834, 66835, 66836 and 66837) were introduced in November 2014 to replace the two previous numbers (66608 and 66609) and improve quality use of testing. This report analyses data from the Medicare statistical reporting tool for the first 8 months (November 2014 to June 2015) since the introduction of the new MBS numbers and guidelines.

The present study found that there had been a marked reduction in benefits paid for vitamin D testing (Box). In absolute terms, there was a saving of about $39.46 million (an average fall of 42%) compared with the same time period the year before. The greatest fall occurred in the summer month of February 2015 but the trend continued in the winter months. The number of services for vitamin D per 100 000 population fell from 18 140 in 2013–14 to 14 415 in 2014–15. The savings to the end of the 2014–15 financial year equate to about $42 million and, if the trend continues (ie, a reduction of 42%), the annual savings will be close to $64 million, reducing the annual spend to $60 million.

The new policy has almost halved expenditure in a short period of time and, if sustainable, will result in a large amount of funds to be reinvested. Before this intervention there had been an unsustainable growth in vitamin D testing. This report highlights the impact of various strategies including analysis of general practitioner test-ordering patterns and quality use of pathology testing policy based on good clinical practice and evidence-based medicine. The report highlights the value of regular monitoring and publication of all high-cost and high-volume pathology test item numbers, which will allow professional societies as well as individual clinicians to monitor trend data to look for opportunities to reinvest the scarce health dollar. New real-time business intelligence and Big Data tools have made this task easier.4

The study is limited by the nature of the MBS data, which capture only the number and dollar benefit of service. Further, patient-level data analysis could shed light on appropriateness of testing.

Although a large proportion of Australians (between 31% and 58%) are estimated to have vitamin D deficiency (defined as serum 25-hydroxyvitamin D levels < 50 nmol/L5), according to season, moderate to severe deficiency is uncommon and only present in about 4% of people.2,6 The new testing requirements should allow better targeting of those at greatest risk and those who will benefit most.