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\begin{document}

\title{Improving Vitamin D testing and supplementation in children with
newly-diagnosed cancer: A Quality Improvement Initiative at Rady
Children's Hospital San Diego}



\author[1]{Ksenya Shliakhtsitsava}%
\author[2]{Erin  Stucky Fisher}%
\author[3]{Erin Trovillion}%
\author[2]{Kelly  Bush}%
\author[4]{Dennis Kuo}%
\author[2]{Ron Newfield}%
\author[5]{Courtney Thornburg}%
\author[2]{William Roberts}%
\author[6]{Paula Aristizabal}%
\affil[1]{UT Southwestern Medical}%
\affil[2]{University of California San Diego}%
\affil[3]{Atrium Health}%
\affil[4]{University of California San Diego School of Medicine}%
\affil[5]{Rady Children’s Hospital-San Diego}%
\affil[6]{Univeristy of California San Diego, Rady Children's Hospital San Diego}%


\vspace{-1em}



  
  \date{May 08, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: Vitamin D deficiency and insufficiency have been associated
with poorer health outcomes. Children with cancer are at high risk for
Vitamin D deficiency and insufficiency. At our institution, we
identified high variability in Vitamin D testing and supplementation in
this population. Of those tested, 65\% were Vitamin D
deficient/insufficient. We conducted a quality improvement (QI)
initiative with aim to improve Vitamin D testing and supplementation
among children aged 2-18 years old with newly-diagnosed cancer to [?] 80\%
over 6 months. Methods: An inter-professional team reviewed baseline
data, then developed and implemented interventions using
Plan-Do-Study-Act (PDSA) cycles. Barriers were identified using QI
tools, including lack of automated triggers for testing and inconsistent
supplementation criteria and follow-up testing post-supplementation.
Interventions included an institutional Vitamin D guideline, clinical
decision-making tree for Vitamin D deficiency, insufficiency and
sufficiency, electronic medical record triggers, and automated testing
options. Results: Pre-intervention: N=26 patients, four (15\%) had
baseline Vitamin D testing; two (8\%) received appropriate
supplementation. Post-intervention: N=33 patients; 32 (97\%) had
baseline Vitamin D testing; 33 (100\%) received appropriate
supplementation and completed follow-up testing timely (6-8 weeks
post-supplementation). Change was sustained over 24 months. Conclusions:
We achieved and sustained our aim for Vitamin D testing and
supplementation in children with newly-diagnosed cancer through
inter-professional collaboration of hematology/oncology, endocrinology,
hospital medicine, pharmacy, nursing, and information technology. Future
PDSA cycles will address patient compliance with Vitamin D
supplementation and impact on patients' Vitamin D levels.%
\end{abstract}%



\sloppy


\textbf{Improving Vitamin D testing and supplementation in children with
newly-diagnosed cancer: A Quality Improvement Initiative at Rady
Children's Hospital San Diego}

Ksenya Shliakhtsitsava MD MAS\textsuperscript{1-2}, Erin Stucky Fisher
MD\textsuperscript{3}, Erin M. Trovillion MD\textsuperscript{1,4}, Kelly
Bush MD\textsuperscript{1,5}, Dennis John Kuo MD MS\textsuperscript{1},
Ron S. Newfield MD\textsuperscript{6}, Courtney D. Thornburg MD
MS\textsuperscript{1,3}, William Roberts MD\textsuperscript{1,5}, Paula
Aristizabal MD MAS\textsuperscript{1,5,7}

\textsuperscript{1} Department of Pediatrics, Division of Pediatric
Hematology/Oncology, University of California, San Diego/Rady Children's
Hospital San Diego, San Diego, CA

\textsuperscript{2}Now with Department of Pediatrics, Division of
Pediatric Hematology/Oncology, University of Texas Southwestern, Dallas,
TX

\textsuperscript{3} Department of Pediatrics, Division of Pediatric
Hospital Medicine, University of California, San Diego/Rady Children's
Hospital San Diego, San Diego, CA

\textsuperscript{4}Now with Department of Pediatrics, Division of
Pediatric Hematology/Oncology, Atrium Health, Levine Children's Cancer
and Blood Disorders, Charlotte, NC

\textsuperscript{5} Quality Improvement Committee, Division of Pediatric
Hematology/Oncology, Rady Children's Hospital San Diego, San Diego, CA

\textsuperscript{6} Department of Pediatrics, Division of Pediatric
Endocrinology, University of California San Diego/Rady Children's
Hospital San Diego, San Diego, CA

\textsuperscript{7} Population Sciences, Disparities and Community
Engagement, University of California San Diego Moores Cancer Center, La
Jolla, CA

\textbf{Corresponding author:}

Ksenya Shliakhtsitsava, MD, MAS

5323 Harry Hines Blvd.

Dallas, TX 75390

Phone: 214-456-5815

Fax: 214-648-3122

Email: Ksenya.Shliakhtsitsava@UTSouthwestern.edu

\textbf{Abstract word count:} 237

\textbf{Main Text word count:} 3,127

\textbf{Number of Tables:} 0

\textbf{Number of Figures:} 5

\textbf{Supporting Information files: 0}

\textbf{Running title:} Vitamin D testing and supplementation

\textbf{Keywords:} pediatric cancer, Vitamin D deficiency, Vitamin D
supplementation, quality improvement, clinical guidelines

\textbf{Abbreviations key:}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Abbreviation} & \textbf{Word}\tabularnewline
\midrule
\endhead
BPA & Best Practice Advisory\tabularnewline
CAR & Chimeric antigen receptor\tabularnewline
ng/ml & Nanogram/milliliter\tabularnewline
PDSA & Plan-Do-Study-Act\tabularnewline
QI & Quality Improvement\tabularnewline
UVB & Type B ultraviolet\tabularnewline
\bottomrule
\end{longtable}

\textbf{Previously presented at (poster presentations):}

Improving the approach for Vitamin D diagnostic testing and
supplementation in newly diagnosed pediatric cancer patients at Rady
Children's Hospital San Diego. Pediatrics Research Symposium, San Diego,
January 2017.

You Can't Find What You Don't Seek: Vitamin D Testing and Treatment in
Pediatric Cancer Patients. PAS, San Francisco, May 2017.

\textbf{Abstract}

\textbf{Background} : Vitamin D deficiency and insufficiency have been
associated with poorer health outcomes. Children with cancer are at high
risk for Vitamin D deficiency and insufficiency. At our institution, we
identified high variability in Vitamin D testing and supplementation in
this population. Of those tested, 65\% were Vitamin D
deficient/insufficient. We conducted a quality improvement (QI)
initiative with aim to improve Vitamin D testing and supplementation
among children aged 2-18 years old with newly-diagnosed cancer to [?] 80\%
over 6 months.

\textbf{Methods:} An inter-professional team reviewed baseline data,
then developed and implemented interventions using Plan-Do-Study-Act
(PDSA) cycles. Barriers were identified using QI tools, including lack
of automated triggers for testing and inconsistent supplementation
criteria and follow-up testing post-supplementation. Interventions
included an institutional Vitamin D guideline, clinical decision-making
tree for Vitamin D deficiency, insufficiency and sufficiency, electronic
medical record triggers, and automated testing options.

\textbf{Results:} Pre-intervention: N=26 patients, four (15\%) had
baseline Vitamin D testing; two (8\%) received appropriate
supplementation. Post-intervention: N=33 patients; 32 (97\%) had
baseline Vitamin D testing; 33 (100\%) received appropriate
supplementation and completed follow-up testing timely (6-8 weeks
post-supplementation). Change was sustained over 24 months.

\textbf{Conclusions:} We achieved and sustained our aim for Vitamin D
testing and supplementation in children with newly-diagnosed cancer
through inter-professional collaboration of hematology/oncology,
endocrinology, hospital medicine, pharmacy, nursing, and information
technology. Future PDSA cycles will address patient compliance with
Vitamin D supplementation and impact on patients' Vitamin D levels.

\textbf{Manuscript word count 3,124}

\textbf{Introduction}

Vitamin D plays an important role in calcium homeostasis and bone
health.\textsuperscript{1, 2} Large ecological studies have suggested a
link between Vitamin D deficiency and low UVB irradiation with increased
cancer incidence and mortality.\textsuperscript{3, 4} These studies
highlight a broader role for Vitamin D in the human body than previously
believed, with effects on immune function, metabolism\textsuperscript{5,
6} and cancer pathophysiology.\textsuperscript{7, 8}

Adequate calcium and Vitamin D levels are important for growing children
and essential for adult bone health. Adequate calcium and Vitamin D
intake, in conjunction with adequate physical activity, are recommended
for cancer survivors, as well as for the general population. Children
diagnosed with acute lymphoblastic leukemia are treated with systemic
corticosteroids and have increased rates of skeletal complications such
as osteoporosis and vertebral fractures during and after their
treatment.\textsuperscript{9, 10} Additionally, suboptimal Vitamin D
levels have been associated with lower survival rates after stem-cell
transplantation\textsuperscript{11} and in patients with Hodgkin
Lymphoma.\textsuperscript{8}

Data on Vitamin D deficiency and insufficiency among children with
newly-diagnosed cancer are very limited. Clinical research and Quality
Improvement (QI) initiatives aimed at improving Vitamin D status in this
population are lacking. We have previously reported that Vitamin D
deficiency and insufficiency are common in children with newly-diagnosed
cancer. Hispanic patients, females and older children were at higher
risk for Vitamin D deficiency and insufficiency at our
institution.\textsuperscript{12}

At the University of California San Diego and Rady Children's Hospital
San Diego, we noted high variability in Vitamin D testing,
supplementation and follow-up testing post-supplementation for children
with newly-diagnosed cancer. We conducted a QI initiative from November
1, 2015 to June 30, 2016 with the global aim to improve overall bone
health among children with newly-diagnosed cancer by standardizing
Vitamin D testing and supplementation.

\textbf{Methods}

\textbf{Clinical Setting and Electronic Medical Record}

This study was conducted at the University of California San Diego and
Rady Children's Hospital San Diego. Rady Children's Hospital is a large
tertiary academic institution. Pediatric cancer care is provided at the
Peckham Center for Cancer and Blood Disorders, the largest pediatric
cancer care facility in San Diego, Riverside~and Imperial counties,
providing care for children and adolescents with blood disorders and
cancer diagnoses in a region that includes around one million children.
Approximately 260 new cases of pediatric cancer are diagnosed annually
at our institution. Most patients require treatment with chemotherapy,
radiation, immunotherapy, stem-cell transplant, or a combination of
these modalities.

During clinic visits and hospital admissions, patients with cancer are
seen either by advance practice providers, resident and fellow
physicians with a supervising pediatric hematology/oncology attending
physician acting as the preceptor, or solely by an attending physician.
All clinical documentation is completed electronically in a commercial
electronic medical record (EMR) {[}Epic\selectlanguage{ngerman}\textsuperscript{®} Systems
Corporation, Verona, Wisconsin{]}, which was implemented six years prior
to the beginning of our QI initiative.

\textbf{Target oncology population}

We previously conducted a retrospective research study to assess Vitamin
D status and its socio-demographic and clinical correlates in 163
children with cancer, using 25-hydroxy vitamin D (25(OH)D)
concentrations. Based on the Endocrine Society
guidelines,\textsuperscript{13} we found that 65\% of the patients with
newly-diagnosed cancer had low Vitamin D levels. Fifty-two patients
(32\%) were Vitamin D deficient, and 53 (33\%) were insufficient. Age
over 10 years, Hispanic ethnicity, and female sex were significantly
associated with lower 25(OH)D concentration at
diagnosis.\textsuperscript{12} Based on these research findings, we
initiated our QI initiative in November 2015. Prior to the start of the
project, our institution did not have a written guideline for Vitamin D
testing, supplementation, and follow-up testing post-supplementation in
children with newly-diagnosed cancer. Testing for Vitamin D and
supplementation was done at the discretion of the treating oncology
provider. Our QI initiative included children with newly-diagnosed
cancer 2-18 years of age who needed treatment with chemotherapy and/or
radiation.

\textbf{QI Team and Specific Measurable Achievable Relevant and Timely
(SMART) Aim}

After reviewing the data from our retrospective study revealing high
prevalence of Vitamin D deficiency and insufficiency, we assembled an
inter-professional QI team.

Our QI team followed the Institute for Healthcare Improvement's Model
for Improvement\textsuperscript{14} and the QI leader completed formal
QI training. The QI leader was a pediatric Hematology/Oncology physician
who worked closely with the team that included physician champions,
nursing staff, QI advisors, and content experts from pediatric
hematology/oncology, hospital medicine, pediatric endocrinology and
information technology (IT).

In person QI team meetings were held biweekly beginning with the
planning phase and throughout the project to address interventions,
discuss unexpected observations and problems encountered, review study
data and decide on interventions to be implemented.

The entire team participated in development of the Key Driver and
Ishikawa diagrams (Figures 1 \& 2), the SMART Aim, the decision-making
tree (Figure 3) and reviewed the Plan-Do-Study-Act (PDSA) cycles. Input
from other key stakeholders (physicians, advance practice providers,
oncology case managers, pharmacists, inpatient and outpatient nurses)
was obtained about potential barriers and facilitators to Vitamin D
testing at the time of initial cancer diagnosis and proposed
supplementation strategies. The QI team leader contributed approximately
six hours of time each week during the first four months of the project
and then approximately four hours per week during subsequent months.

Our SMART Aim was: From February 1 to June 30, 2016, compliance with
institutional guidelines for Vitamin D testing and supplementation in
children with newly-diagnosed cancer (aged 2-18 years old) will be \selectlanguage{english}[?]80\%
from a baseline of 0\% and sustained over subsequent months.

\textbf{Interventions}

Our institution has successfully used and sustained evidence-based order
sets that include clinical decision-making elements for other
conditions.\textsuperscript{15} The team used this existing framework,
QI tools, and the PDSA methodology\textsuperscript{14} to understand
barriers to improvement and implement interventions. To enable rational
design of interventions, the QI team identified factors that drive the
Vitamin D testing, supplementation and follow-up testing
post-supplementation. Potential barriers and facilitators and primary
drivers are described in Ishikawa (Figure 1) and Key Driver (Figure 2)
diagrams.

After considering the feasibility, evidence, and local culture, the team
decided on the following interventions: 1) development of an
institutional guideline for Vitamin D testing, supplementation and
follow-up testing post-supplementation; 2) education on Vitamin D
deficiency and insufficiency testing and supplementation for oncology
providers; 3) creation and distribution of a clinical decision-making
tree for Vitamin D deficiency, insufficiency, and sufficiency {[}Figure
3{]}; 4) incorporation of EMR triggers and Vitamin D automated testing
options; 5) inclusion of the Vitamin D laboratory order into the
pre-existing oncology order sets; and 6) creation of a Best Practice
Advisory (BPA) alert to be triggered if the patient did not have recent
Vitamin D testing, or if testing was done but the patient was not taking
Vitamin D.

\emph{PDSA \#1: Pre-intervention assessment, Ishikawa and Key Driver
diagrams, process map, and development of institutional guideline
(November 1, 2015 to January 31, 2016).}

Ishikawa results were compiled and analyzed, and a process map was
completed. Barriers such as lack of automated triggers/reminders for
testing, inconsistent criteria used for testing and supplementation, and
inability to obtain follow-up testing post-supplementation were
identified. Key drivers included: Physicians' knowledge about when to
test and how to supplement Vitamin D; guideline and decision-making tree
widely available; integration into clinical workflows and facilitated by
automated triggers in EMR; and leadership awareness and support (Figure
2). In collaboration with a pediatric endocrinologist we reviewed
national best practices and created an institutional guideline and
clinical decision-making tree for Vitamin D testing, supplementation and
follow-up testing post-supplementation (Figure 3). We utilized 25(OH)D
as the most accurate way to measure Vitamin D status in our patients.
The pediatric endocrinologist provided input regarding supplementation
and follow-up testing post-supplementation based on the Endocrine
Society Guidelines.\textsuperscript{13} We defined Vitamin D deficiency
as 25(OH)D concentration of \textless{}20 ng/ml, insufficiency \selectlanguage{english}[?]20 and
\textless{}30 ng/ml, and sufficiency \selectlanguage{english}[?]30 ng/ml. Based on the patient's
25(OH)D concentration, supplementation was prescribed and follow-up
testing post-supplementation was completed per the clinical
decision-making tree (Figure 3).

\emph{PDSA \#2: Implementation phase (February 1, 2016 to June 30,
2016).}

We conducted an educational intervention focused on Vitamin D deficiency
and insufficiency testing and supplementation for oncology providers
(physicians and advance practice providers), nurses, case managers, and
pharmacists via direct one-on-one in-person communication, structured
in-person lectures and secure e-mails. The decision-making tree was
distributed as hardcopy and was made widely available and posted in the
inpatient unit, outpatient clinic working space, and the secure shared
oncology folder online. EMR triggers and Vitamin D automated testing
options were incorporated. A Vitamin D laboratory order was added into
the pre-existing oncology admission order set as well as in Beacon
chemotherapy treatment plans, an Epic\textsuperscript{(r)} oncology module
for physicians and pharmacists to create treatment and supportive care
plans based on standardized protocols that also allows for easy
modification. A BPA alert was created that triggered if the patient had
a chemotherapy treatment plan in place but did not have recent Vitamin D
testing, or if Vitamin D testing was done but the patient was not taking
Vitamin D.

In order to assess end-user value, we created a 6-question secure online
de-identified survey utilizing the
SurveyMonkey\textsuperscript{(r)}platform. The survey was administered to
oncology providers after interventions were executed. The survey
included the following questions: 1) What are the barriers preventing
Vitamin D initial testing at the time of cancer diagnosis? (Free text
response); 2) Do you use the Vitamin D supplementation decision-making
tree? (Likert scale); 3) Do you find the Vitamin D supplementation
decision-making tree helpful? (Likert scale); 4) What are the barriers
preventing repeat Vitamin D testing at 6-8 weeks after Vitamin D
supplementation initiation? (Free text response); 5) Do you use the
Vitamin D BPA? (Likert scale); 6) Do you find Vitamin D BPA reminders
helpful? (Likert scale). For questions 2, 3, 5 and 6, a traditional
Likert scale with 1-5 ratings was used to assess value/usefulness, with
1 = none, 2 = little, 3 = some, 4 = moderately high, and 5 = high. The
percentage of results for ``moderately high`` or ``high'' for each
question were reported.

\textbf{Data collection and analysis}

The QI leader identified newly-diagnosed patients through an automated
new diagnosis banner in the EMR. We performed frequent monitoring of
newly-diagnosed patients to ensure that all cases were captured.

Standardized definitions for Vitamin D deficiency, insufficiency and
sufficiency were used.\textsuperscript{13} EMRs of patients aged 2--18
years old with newly-diagnosed cancer were reviewed, including provider
notes, lab testing orders and results, and prescriptions. Rates of
Vitamin D testing, supplementation and follow-up testing
post-supplementation were obtained at different time points, from
November 1, 2015 to January 31, 2016 (pre-intervention) and from
February 1, 2016 to June 30, 2016 (post-intervention), and averaged over
seven-day periods. To assess sustainability, we obtained data every two
months until June 2018.

Process measures of testing and supplementation were chosen to assess
the system improvement; supplementation was also identified as a
feasible proxy for clinical outcome improvement by the team. An
additional process measure of perceived utility of the decision-tree and
automated triggers was chosen to assess end-user buy-in.

Weekly documentation rates were plotted on a run chart during the study
phase of each PDSA cycle to identify non-random signals of change in
Vitamin D testing (Figure 4) and supplementation and follow-up testing
post-supplementation (Figure 5). For statistical process control, a
p-control chart was used to detect special cause variation. Both the run
chart and p-control chart were generated with Microsoft Excel QI Macros.
To assess process measures including use and perceived utility of the
decision-making tree and automated triggers, we conducted the survey
described above.

\textbf{Ethics and Project Communication}

This QI study was reviewed and deemed to not be human subjects research
and

a QI exemption waiver was granted by the University of California San
Diego/Rady Children's Hospital San Diego Institutional Review Board.

The results, successes and barriers we encountered during the project
were shared with the oncology providers on a regular basis.
Communications included weekly updates on the progress of the
initiative, monthly updates to division leadership, and annual reports
to hospital leadership.

\textbf{Results}

Twenty-six patients were evaluated during the initial three months (PDSA
\#1): 11 patients (42\%) with hematological malignancies, 15 patients
(58\%) with malignant solid tumors, mean age at the time of diagnosis
was 8.9 years +-5.4, 10 patients (38\%) were males and 16 (62\%) females.
Only four (15\%) patients had baseline Vitamin D testing. Three patients
had concentrations that should have required supplementation, but only
two (66\%) were prescribed the appropriate supplement.

Thirty-three patients were included in the post-intervention group (PDSA
\#2): 27 patients (88\%) with hematological malignancies and six
patients (12\%) with malignant solid tumors, mean age at the time of
diagnosis was 8.6 years +-5.2, 19 patients (57\%) were males and 14
(43\%) females. Thirty-two (97\%) had baseline Vitamin D testing
performed. Thirty-three (100\%) received appropriate supplementation and
completed follow-up testing at the appropriate time (6-8 weeks
post-supplementation). Compared to pre-intervention, we tested 27 more
patients and identified 10 more patients. From July 2016 to June 2018,
over 80\% of patients had both baseline Vitamin D testing performed,
received appropriate supplementation and completed follow-up testing
post-supplementation, demonstrating sustainability over time (Figures 4
and 5). The perceived utility and use survey was completed by 16 out of
24 clinicians and perceived utility of the decision-making tree was
67\%, use of decision-making tree reached 83\%, and perceived utility of
automated triggers was 86\%.

\textbf{Discussion}

Through inter-professional collaboration with hematology/oncology,
endocrinology, hospital medicine, pharmacy, and IT, we successfully
improved the testing, diagnosis, supplementation and monitoring of
Vitamin D deficiency and insufficiency for children with newly-diagnosed
cancer and demonstrated sustainability over 24 months. We achieved and
sustained our aim to improve Vitamin D testing, adequate Vitamin D
supplementation and accurate and timely follow-up testing
post-supplementation. We exceeded our SMART Aim of \selectlanguage{english}[?]80\% compliance with
the newly developed institutional guideline and clinical decision-tree
after implementation and sustained our aim of \selectlanguage{english}[?]80\% over time.

Children with cancer are at high risk for Vitamin D deficiency and
insufficiency due to inadequate sun exposure and treatment-related
complications, such as poor diet, hepatotoxicity and/or nephrotoxicity
of chemotherapeutic agents, impaired absorption due to mucositis and/or
colitis, and interference of Vitamin D metabolism by glucocorticoids.
Current Endocrine Society Clinical Practice Guidelines on the
evaluation, treatment, and prevention of Vitamin D deficiency recommend
testing patients at risk for deficiency with the measurement of serum
25(OH)D concentrations, followed by treatment with either oral Vitamin
D2 or Vitamin D3 supplementation in patients found to be deficient or
insufficient.\textsuperscript{13} Research from our group showed that
Vitamin D supplementation significantly increases serum 25(OH)D
concentrations.\textsuperscript{12}

Low bone mineral density has been reported in pediatric cancer survivors
even several years after completion of cancer
therapy.\textsuperscript{16, 17} Current national survivorship
guidelines\textsuperscript{18} recommend a baseline bone mineral density
evaluation followed by laboratory assessments, in order to evaluate bone
health beginning two years after therapy completion, particularly for
patients with history of acute lymphoblastic
leukemia.\textsuperscript{17, 18}

Our QI methodology led to successful establishment of the QI team, with
specific roles for team members; continued communication of the QI
initiative aim and progress to staff; two-way feedback on processes
implementation; and accurate and efficient patient identification for
data analysis. The EMR-based interventions implemented by the IT team
for automated BPA alerts and triggers for Vitamin D laboratory testing
and monitoring may have contributed to the observed increase in
compliance with the newly developed institutional guideline for Vitamin
D testing and supplementation. After conducting educational
interventions regarding the standardized criteria for Vitamin D
deficiency and insufficiency diagnoses, and the clinical decision-making
tree for adequate supplementation, we observed a significant increase in
testing and supplementation rates. This finding is consistent with
previous studies showing that passive EMR features such as BPA alerts
need to be accompanied by complementary strategies such as educational
interventions to improve compliance with guidelines and achieve
sustainability over time.\textsuperscript{19}

Regular feedback about group performance, compared to prior performance
were positively received, and helped motivate oncology providers to
further adhere to the newly implemented practices. Although additional
research is needed to establish the benefit of performance feedback
(individual or group) in improving guideline compliance and sustained
culture change, our findings support previous studies showing the
positive impact of providing timely feedback on improving clinical
practice and EMR documentation.\textsuperscript{20} Additionally,
hospital leadership support and awareness of the clinical need, and
frequent communication with key stakeholders contributed to achieving
and sustaining our aim.

There are several limitations in our project to be discussed. First, we
focused on one aspect of clinical care in a specific setting. Second, we
reviewed data for three months prior to our interventions on a small
group of patients. Studying pre-intervention data in a larger group and
over a longer period may help to determine temporal variation. Third,
our EMR interventions were geared toward BPA alerts and automated
testing options in our admission and chemotherapy order sets, which are
specific components of our EMR and may not be reproducible in other
practices that do not use a similar EMR. However, as most centers
managing pediatric cancer have had EMRs in place for many years, this
limitation should be resolvable. While motivations for performing
testing or prescribing supplementation were not explored, providers'
perceived utility of the decision-making tree and automated triggers,
and positive feedback of frequent reports and reminders, contributed to
steady improvement over the first 4 months of the QI initiative and
sustainability for 24 months. Additionally, our QI initiative could have
been further strengthened by assessing balancing measures to determine
whether there were unintended consequences in other parts of the
clinical workflow as a result of our QI initiative, such as
documentation of time spent by the provider reviewing the clinical
decision-making tree, ordering tests and prescribing supplementation.

\textbf{Conclusion}

Our inter-professional QI initiative, which incorporated automated tools
within the EMR, demonstrated success in improving Vitamin D testing and
supplementation in children with newly-diagnosed cancer in a large
tertiary academic institution with a high prevalence of Vitamin D
deficiency and insufficiency. This QI approach may be replicated in
similar settings. Future PDSA cycles will address patient compliance
with Vitamin D supplementation. QI methodology will continue to be used
in the future to improve adherence to other testing and medication
prescribing procedures for children with cancer at our institution.

\textbf{Conflict of Interest statement}

This project was partially supported by the National Cancer Institute
K08 CA230306 (Aristizabal) and Dedman Family (Shliakhtsitsava). The
content is solely the responsibility of the authors and does not
represent the official views of the National Cancer Institute or the
National Institutes of Health.

\textbf{Acknowledgements}

We thank the pediatric hematology/oncology team and the Quality
Improvement Committee (Elizabeth Sheldon RN, Lindsay Colliton RN, Sally
Steiner RN, Margaret Fitzgerald RN, Teresa Cassidy RN and Stacey Brown
RN) at the Peckham Center for Cancer and Blood Disorders at Rady
Children's Hospital. The content is solely the responsibility of the
authors. We thank Adam Felton for Electronic Medical Record and
EPIC\textsuperscript{(r)} support.

\textbf{References}

1. Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary
reference intakes for calcium and vitamin D from the Institute of
Medicine: what clinicians need to know. \emph{J Clin Endocrinol Metab} .
Jan 2011;96(1):53-8. doi:10.1210/jc.2010-2704

2. Medicine Io. Conclusions about Vitamin D deficiency in the US and
Canada. 2011.

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\textbf{Legend}

FIGURE 1 Ishikawa diagram.

FIGURE 2 Key driver diagram.

FIGURE 3 Decision-Making Tree.

FIGURE 4 Vitamin D testing rates. P-chart with vitamin D testing and
annotated improvement interventions in orange. Desired direction of
change is noted in bold green arrow. GD Guideline development; E,
Education; DT, Decision making tree; BPA, Best Practice Alert; CL,
centerline; LCL, lower control limit; UCL, upper control limit.
Plan-Do-Study-Act (PDSA) Cycle 1 = GD and DT development; Cycle 2 = E,
DT implementation, Electronic Medical Record (EMR) triggers (BPA).

FIGURE 5 Vitamin D supplementation and follow-up post-supplementation
rates. P-chart with vitamin D supplementation. Desired direction of
change is noted in bold green arrow. E, Education; DT, Decision making
tree; BPA, Best Practice Alert; CL, centerline; LCL, lower control
limit; UCL, upper control limit. Plan-Do-Study-Act (PDSA) Cycle 2 = E,
DT implementation, Electronic Medical Record (EMR) triggers (BPA).\selectlanguage{english}
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