Aim

1. 100% of patients should have their vitamin D levels checked at diagnosis’ as stated in the current trust guideline for the management of vitamin D deficiency Treatment and Prevention.

2. 100% of patients who had a baseline vitamin D level had these acted upon if necessary following the recommendations in the trust guideline.

3. All of the patients who were given treatment had been prescribed were given an appropriate dose as stated in the trust guideline.

AimThese standards are supported by the recommendations in 2016 by Public Health England (PHE) that everyone (regardless of age and ethnicity) needs vitamin D equivalent to an average daily intake of 10 micrograms via supplementation.^{2 3}

Method This retrospective audit was conducted using internal clinical and prescribing programmes to access patient records and medical histories to retrieve data. The inclusion criteria for patients included in this audit were all new diagnoses of malignant haematological and oncological disease over a 6 month period, from April 2018-October 2018. The data collected for these patients were: if they had been tested for Vitamin D, the date of the test and their level of total vitamin D level Serum total 25-hydroxyvitamin D concentration. Patient data from the electronic prescribing system was utilised to check if patients had been prescribed vitamin D. Once data completed, patients with vitamin D levels, assessed against trust guidelines to determine if appropriately treated.

Results A total of 78 patients met the inclusion criteria, where 56% of patients were tested for vitamin D during admission. Of the 78 patient, 43 were oncology patients and 33 haematology patients.In the oncology cohort (n=15) only 35% were tested whereas 83% of haematology patients (n=28) were tested. Of the haematology cohort of patients who were tested (83%): 69% had sufficient levels of vitamin D (serum total 25-hydroxyvitamin D concentration >50 nmol/L); 11% had insufficient levels (25–50 nmol/L) and 3% were deficient (< 25 nmol/L). Of the oncology cohort who were tested (35%): 28% had sufficient levels of vitamin D; 5% of patients had insufficient levels; 2% were deficient. 6% of haematology patients and 5% of oncology patients with sufficient levels of vitamin D received treatment that was not indicated. Furthermore, the 5% of oncology patients with insufficient levels of vitamin D did not receive any treatment.

Conclusion The standards set for this audit were not met. It is concerning that those with low levels were not treated effectively and are at risk of complications. Although the findings of this audit may not be a true reflection of the entire patient population due to the small cohort size; the insight into at risk patients suggests there is a need to improve practice and reach 100% for all the aims of this audit.

To improve smart and efficient prescribing of medication, clinicians should adhere to the revised trust ‘Guideline for the Management of vitamin D deficiency’ to guide their decisions on initiating therapy. Pharmacists should check vitamin D levels for all new admissions and follow up as appropriate for any pending tests. Having a default test built into the current new prescribing system will also support in improving the results.

References

1. Holick, M. ( 2019). Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. [online]Available at: https://academic.oup.com/ajcn/article/79/3/362/4690120

2. Public Health England. Statistical Summary: National Diet and Nutrition Survey: results from Years 1 and 9 (combined) of the Rolling Programme (2008/09 – 2016/17). https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/772430/NDNS_Y1-9_statistical_summary.pdf

3. GOV.UK. ( 2019). SACN vitamin D and health report. [online]Available at: https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report

4. Great Ormond Street Hospital Trust guideline for the management of Vitamin D deficiency Treatment and Prevention.