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Background: Exponential increases in nonindicated, low-value vitamin D testing have been reported over the past 15 years. Downstream effects of such testing have not been well quantified. Methods: The purpose of this study was to describe patterns of vitamin D testing within primary care of a large regional health system and to explore downstream health service utilization subsequent to nonindicated testing. Instances of vitamin D testing in 2015 were obtained by an electronic health record-automated search. A subset of patients for whom vitamin D testing was classified as nonindicated was identified, and vitamin D-related service utilization was tracked for 24 months. Results: Of the 77,836 adult primary care patient records identified in 2015, vitamin D tests were conducted on 8,042 (10.3%), with 24.3% of tests yielding abnormal results. In the nonindicated test subset (n = 574), substantial clinical variability was illustrated by 85 care pathways and 26 vitamin D prescriptions. Forty-five percent of abnormal vitamin D lab tests were not followed up with repeat vitamin D tests. Vitamin D-related services (laboratory tests, imaging, and prescriptions) occurred at an average rate of 1.6 services per patient during the 24 months following nonindicated vitamin D testing. Some of these services were also classified as nonindicated. Conclusions: Evidence of a health service cascade following nonindicated vitamin D testing exists. Opportunities for improved consistency and quality of care related to vitamin D were observed in our health system. These results may inform clinical pathways related the prevention, evaluation, and treatment of low vitamin D.

Background: Despite the current evidence of preventive screening effectiveness, rates of breast, cervical, and colorectal cancer in the United States fall below national targets. We evaluated the efficacy and feasibility of combining practice facilitation and academic detailing quality improvement (QI) strategies to help primary care practices increase breast, cervical, and colorectal cancer screening among patients. Methods: Practices received a 1-hour academic detailing session addressing current cancer screening guidelines and best practices, followed by 6 months of practice facilitation to implement evidence-based interventions aimed at increasing patient screening. One-way repeated measures analysis of variance compared screening rates before and after the intervention, provider surveys, and TRANSLATE model scores. Qualitative data were gathered via participant focus groups and interviews. Results: Twenty-three practices enrolled in the project: 4 federally qualified health centers, 10 practices affiliated with larger health systems, 4 physician-owned practices, 4 university hospital clinics, and 1 nonprofit clinic. Average screening rates for breast cancer increased by 13% (P = .001), and rates for colorectal cancer increased by 5.6% (P = .001). Practices implemented a mix of electronic health record data cleaning workflows, provider audits and feedback, reminder systems streamlining, and patient education and outreach interventions. Practice facilitators assisted practices in tailoring interventions to practice-specific priorities and constraints and in connecting with community resources. Practices with resource constraints benefited from the engagement of all levels of staff in the quality improvement processes and from team-based adaptations to office workflows and policies. Many practices aligned quality improvement interventions in this project with patient-centered medical home and other regulatory reporting targets. Conclusions: Combining practice facilitation and academic detailing is 1 method through which primary care practices can achieve systems-level changes to better manage patient population health.