(95) Improvement of Vitamin D Levels and DEXA Screening Using a Microsystems Approach

Background: Malabsorption and poor medication adherence results in low vitamin D levels in people with cystic fibrosis (CF). Low bone mineral density (LBMD) occurs due to vitamin D malabsorption, low calcium intake, inactivity, altered sex steroid levels, and inflammation. The University of Texas Health Science Center San Antonio Pediatric CF Center (UTHSCSA PCFC) 2019 center specific data revealed rates of obtaining DEXA scans well below the national average (1.9% vs 16.8%). We did not screen patients for LBMD risk factors. Only 48% of patients had normal vitamin D levels. We transitioned to a new electronic medical record (EMR) in July 2020, and inconsistencies were noted in the vitamin D doses documented in 60% of our patients. Based on this data and the UTHSCSA PCFC goal to achieve the best clinical outcomes, our Center enrolled in the Virtual Improvement Program 6 in November 2020 with the goal of improving the overall bone health of our patients.

Methods: The UTHSCSA PCFC developed specific aims to improve the percentage of patients with normal vitamin D levels from 48% to 60% by 6/1/22 and to increase the percentage of eligible patients who complete DEXA scans from 0% to 50% by 12/31/21. We developed a database to track vitamin D levels and dose documentation, a clinic tool to notify providers of dosing discrepancies and/or low vitamin D levels, and a vitamin D treatment algorithm. A bone density screening tool and a screening/treatment algorithm were developed and utilized to screen all children >8 years of age. We developed educational material related to vitamin D supplementation and age-appropriate exercises to enhance bone health.

Results: The rate of discrepancies in vitamin D dose documentation decreased from 60% to 15% by 3/1/22. The percentage of patients with normal vitamin D levels increased from 48% to 63% by 3/1/22. In July 2021, a clinical pharmacist joined the CF team and reviewed medications/addressed refill issues with every patient, and our hospital pharmacy began to fill vitamin prescriptions. Currently, our pharmacy supplies vitamins to 61% of the clinic population. By 12/31/21, 94% of patients > 8 years of age had LBMD screening and 39% met criteria to get DEXA scans. DEXA scans were completed on 65% of the qualifying patients, and 31% had z scores < -2. Challenges existed in timely scheduling of DEXA scans due to limited availability of equipment and appointments.

Conclusions: Lack of a standardized workflow, transition to a new EMR, and numerous available over the counter vitamin D preparations lead to discrepancies in vitamin D dosing. With improved team communication, better EMR documentation, and adding a clinical pharmacist to our team, we were able to significantly decrease dosing discrepancies. Increased awareness of low vitamin D levels, having a standardized treatment algorithm, and the ability to provide vitamins through our pharmacy despite lack of insurance coverage resulted in higher rates of patients with normal vitamin D levels. Through the development of a standardized screening algorithm, we identified a high proportion of patients with risk factors for LBMD and a significant percentage had abnormal bone density. With improvement in CF care and a more aggressive strategy to optimize vitamin D levels, we expect that fewer patients will be at risk for LBMD.

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