title: A Resident-led Initiative Improves Screening and Treatment for Vitamin D Deficiency in Patients with Hip Fractures.
abstract: BACKGROUND
  Acute hip fractures carry a high risk of morbidity and are associated with low vitamin D levels. Improvements in screening and treating low vitamin D levels may lead to lower fall rates and a lower likelihood of additional fragility fractures. However, patients with low vitamin D levels often remain unassessed and untreated, even after they experience these fractures.
  
  
  OBJECTIVE
  We wished to determine whether a resident-led initiative can improve (1) screening for and (2) treatment of vitamin D deficiency in patients with acute hip fractures.
  
  
  METHODS
  Our department initiated a housestaff-led, quality improvement project focused on screening and treating vitamin D deficiency in patients with acute hip fractures. Screening encompassed checking serum 25-hydroxyvitamin D level during the acute hospitalization, and treating was defined as starting supplementation before discharge when the serum 25-hydroxyvitamin D level was less than 30 ng/mL. To evaluate the efficacy of this program, an administrative database identified 283 patients treated surgically for an acute hip fracture between July 2010 and June 2014. This period included 2 years before program initiation (Year 1, n = 65 patients; Year 2, n = 61 patients), the initial program year (Year 3, n = 66 patients), and the subsequent program year (Year 4, n = 91 patients). Followup was extended to 6 weeks after treatment with 9.2% (26/282) of patients lost to followup. Eight patients were excluded owing to documented intolerance of vitamin D supplementation. There were no differences regarding patient demographics, fracture type, or treatment rendered across these 4 years. The primary endpoints were the proportion of patients screened and treated for vitamin D deficiency. The secondary endpoint was the continuation of vitamin D supplementation at the patient's 6 week followup, according to the patient's medication list at that visit. This analysis included all patients, assuming those lost to followup had not continued supplementation. ANOVA and chi-square tests were used to evaluate the differences in demographic data and in screening and treating rates.
  
  
  RESULTS
  Screening for vitamin D deficiency improved after initiation of the resident-led quality improvement program, with screening performed for 31% of patients in Year 1 (20/65; odds ratio [OR], 0.44; 95% CI, 0.26-0.75), 20% of patients in Year 2 (12/61; OR, 0.24; 95% CI, 0.13-0.46), 46% of patients in Year 3 (30/66; OR, 0.83; 95% CI, 0.51-1.35), and 88% of patients in Year 4 (80/91; OR, 7.27; 95% CI, 3.87-13.7) (p < 0.001). Vitamin D supplementation was initiated for 33% of patients in Year 1 (21/63; OR, 0.5; 95% CI, 0.30-0.84), 28% in Year 2 (17/61; OR, 0.39; 95% CI, 0.22-0.68), 50% in Year 3 (32/64; OR,1.00; 95% CI, 0.61-1.63), and 76% in Year 4 (65/86; OR, 3.10; 95% CI, 1.89-5.06) (p < 0.001). At early postoperative followup, we saw substantial improvement in the proportion of patients who continued receiving vitamin D supplementation: Year 1, 12% (8/64; OR, 0.14; 95% CI, 0.07-0.30); Year 2, 15% (9/61; OR, 0.17; 95% CI, 0.09-0.35); Year 3, 26% (16/64; OR, 0.33; 95% CI, 0.19-0.59); and Year 4, 46% (40/86; OR, 0.87; 95% CI, 0.57-1.33) (p < 0.001).
  
  
  CONCLUSIONS
  Implementation of a resident-led quality improvement program resulted in higher rates of screening and treating vitamin D deficiency for patients with acute hip fractures. Housestaff-based initiatives may be an effective way to improve care processes that target improvements in bone health.
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave MU320W, Box 0728, San Francisco, CA, 94143, USA.
authors.forename: Drew A
authors.initials: DA
authors.lastname: Lansdown
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave MU320W, Box 0728, San Francisco, CA, 94143, USA.
authors.forename: Amanda
authors.initials: A
authors.lastname: Whitaker
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave MU320W, Box 0728, San Francisco, CA, 94143, USA.
authors.forename: Rosanna
authors.initials: R
authors.lastname: Wustrack
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave MU320W, Box 0728, San Francisco, CA, 94143, USA.
authors.forename: Aenor
authors.initials: A
authors.lastname: Sawyer
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave MU320W, Box 0728, San Francisco, CA, 94143, USA. Erik.hansen@ucsf.edu.
authors.forename: Erik N
authors.initials: EN
authors.lastname: Hansen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006620:Hip Fractures / Q000097:blood / Q000150:complications*; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008403:Mass Screening; D016896:Treatment Outcome; D014807:Vitamin D / Q000031:analogs & derivatives* / Q000097:blood / Q000627:therapeutic use*; D014808:Vitamin D Deficiency / Q000097:blood / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy
chemical_list: D014807:Vitamin D; C104450:25-hydroxyvitamin D