In Birmingham 25% of a study population were found to be vitamin D deficient with the prevalence being higher in those of Asian and Afro-Caribbean origin.1 High rates of deficiency are most evident in areas which have seen an increase in ethnic diversity, including Birmingham, resulting in the resurgence of rickets and hypocalcaemic tetany.2 Department of Health (DoH) guidance issued in 2012 states all children aged 6 months to 5 years should receive daily supplementation.
The audit assessed whether children presenting as outpatients identified as being vitamin D deficient or insufficient were managed as per trust policy3 and estimated cost savings for the trust if patients were supplemented as per DoH guidelines.
The standards set were: a) 100% of children determined to have vitamin D deficiency (<25 nmol/L) were correctly treated using colecalciferol (or equivalent). b) 100% of children determined to have vitamin D insufficiency (=25–50 nmol/L) were correctly supplemented using a multivitamin preparation.
A proforma was designed to capture the required data. The trust biochemistry department provided data from January to October 2012 on all children presenting as outpatients with a vitamin D level recorded. Only data from the first 3 months was used resulting in an audit population of 100 following exclusions. Details regarding treatment and supplementation were obtained using clinical data archive and the pharmacy dispensing system.
Deficiency was identified in 52% of patients with 79% of these being treated correctly. This rose to 91% when only those with sufficient documentation were included. To correctly treat the 52% of patients identified as deficient would cost £7,854. To supplement those same patients as per the DoH guidelines would result in a cost saving of £3278 equating to a saving of approximately £13,000 for the year.
Insufficiency was identified in 48% of patients with only 6% receiving correct supplementation. In many cases GPs were directed to prescribe supplements or patients advised to purchase but guidance on dosing, duration and preparation was lacking in the documentation. Therefore for 71% of patients whether supplementation was correct or incorrect was indeterminable. When those with insufficient documentation were excluded 22% of patients were supplemented correctly. No patients were advised to obtain supplements through the Healthy Start Vitamin scheme.
Neither audit standard was met however the management of deficiency was better than that of insufficiency. Recommendations to improve management within the local area include consistent implementation of policy at doctors' induction, encouraging correct prescribing in primary care through medicines management CCGs and development of shared care guidelines and to improve awareness and knowledge of Healthy Start Vitamins. The audit recommendations encourage consistent working across care settings, but current evidence suggests that implementation ofguidance to manage vitamin D deficiency and insufficiency is unclear 4 therefore in 2014 NICE will be producing public health guidance on the implementation of existing vitamin D guidance to prevent deficiency. This should encourage transparency across care settings, further support our audits and consolidate work the trust intends to do with Public Health through the Local Authority.
Full references will be in the final presentation.