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 ≥80% compliance with
the newly developed institutional guideline and clinical decision-tree
after implementation and sustained our aim of ≥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.13 Research from our group showed that
Vitamin D supplementation significantly increases serum 25(OH)D
concentrations.12
Low bone mineral density has been reported in pediatric cancer survivors
even several years after completion of cancer
therapy.16, 17 Current national survivorship
guidelines18 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.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.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.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.