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Clinical audit of health promotion of vitamin D in one general practice

Clinical audit of health promotion of vitamin D in one general practice Background: The clinical audit of vitamin D health promotion in one Australian general practice was undertaken by measuring health service use and serum 25-hydroxyvitamin D levels in 995 patients aged 45 to 49 years. Findings: Over 3 years, 486 (51%) patients had a Medicare funded Health Assessment. More women (54%) were assessed than men (46%) p = 0.010. Mean 25-OHD was higher for men (70.0 nmol/l) than women (60.3 nmol/l) p < 0.001. More patients had their weight measured (50%) than 25-OHD tested (28%). Among 266 patients who had a 25-OHD test, 68 (26%) had normal levels 80+ nmol/l, 109 (41%) were borderline 51-79 nmol/l, and 89 (33%) were low < 51 nmol/l. Mean 25-OHD was higher in summer (73.7 nmol/l) than winter (54.7 nmol/l) p < 0.001. Sending uninvited written information about 25-OHD had no effect on patients’ subsequent attendance. Conclusions: Health promotion information about vitamin D was provided to 50% of a targeted group of patients over a one-year period. Provision of this information had no effect on the uptake rates of an invitation to attend for a general health assessment. Keywords: Vitamin D, Health promotion, General practice, Clinical audit Findings criteria included all patients registered with IPMC elec- The RACGP (Royal Australian College of General Prac- tronic health records and eligible for a Health Assess- titioner) Red Book provides specific recommendations ment funded through Medicare Item Number 717 (A on vitamin D and sunlight exposure in health promo- policy introduced by the commonwealth government on tion[1]. This clinical audit was initiated when one GP 1st November 2006 meant for patients aged 45 to 49 (general practitioner) at the IPMC (Isabella Plains Medi- years to consult for reasons of health promotion in gen- cal Centre) observed that many patients appeared to be eral practice). deficient in serum vitamin D. The aim of this clinical audit was to evaluate how IPMC managed its health Part 1 Audit promotion surrounding vitamin D. described the characteristics of patients aged 45-49 years who consulted the practice under Item Number 717 Method between November 2006 and October 2008. Practice setting IPMC has 10 full-time equivalent GPs, four practice Part 2 Audit nurses, and five allied health workers who care for a measured the impact of written advice on patients who practice population of 19,417 patients. The audit consulted IPMC for health promotion between October occurred in two parts over a three-year period between 2008 and December 2009. Patients were sent a letter November 2006 and December 2009. The selection inviting them to consult with IPMC. Half were ran- domly selected to receive the invitation only, the other half received the invitation letter as well as specific * Correspondence: Marjan.kljakovic@anu.edu.au Academic Unit of General Practice in the School of General Practice, Rural information contained in a Cancer cosmetics pamphlet and Indigenous Health, at the Australian National University Medical School, [2] on the role of vitamin D and how to obtain a blood PO Box 11 Woden, ACT 2606 Canberra, Australia test. Full list of author information is available at the end of the article © 2012 Kljakovic et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kljakovic et al. Asia Pacific Family Medicine 2012, 11:3 Page 2 of 4 http://www.apfmj.com/content/11/1/3 The variables measured in this audit were the number There were 474 patients (50%) who had their weight of people who attended IPMC under Item Number 717 measured; 473 (50%) had their BMI score calculated; and their serum 25-OHD (25-hydroxyvitamin D) levels, 427 (45%) had their waist measured; 432 (45%) had the serum biomarker of vitamin D. Patients who are their activity score measured; And 266 (28%) had a 25- subsequently found to have a low 25-OHD level are OHD test. Table 1 shows males were significantly hea- routinely retested at six months intervals. The local vier and had larger waists than women, but no differ- laboratory determined the normal range for 25-OHD ence in BMI or activity scores than women. Women was 51 nmol/l to 140 nmol/l: A low level was defined as had significantly lower 25-OHD than men, even though more women had a 25-OHD test taken than men (32% < 51 nmol/l 25-OHD, 51-79 nmol/l was defined border- line, and 80+ nmol/l was defined normal. The season in versus 21%, Pearson Chi-Square = 13.28, df = 1, p < which the test was taken was also measured). Other 0.001). variables included gender, weight, BMI, waist circumfer- Among 486 patients who had a Health Assessment, ence, and the level of activity patients reported they per- 220 patients (45%) did not have a 25-OHD test, 207 formed in daily life. (Ranked on a 14-point Likert scale patients (43%) had one test, 46 patients (9.5%) had two where 0-points was no daily physical activity to 14- 25-OHD tests, and 13 patients (3%) had three 25-OHD points was 60 minutes of activity daily at a very strenu- tests. ous level). Among the 266 patients who had 25-OHD tests, 89 Data were coded in excel and analysed in PASW Sta- patients (33%) had low 25-OHD of < 51 nmol/l, 109 tistics 18™ comparing differences between categories patients (41%) had borderline 25-OHD of 51-79 nmol/l, using the non-parametric chi squared test where and 68 patients (26%) had normal 25-OHD of 80+ appropriate. nmol/l. Table 2 shows that 59 patients (66%) had a fol- Ethical approval was not sought for this audit because low up 25-OHD test six months later. Among the 56 it met the National Health and Medical Research Coun- patients who had low 25-OHD at initial assessment, 19 cil’s criteria for exemption [3], namely the audit was patients (34%) remained at a low level at follow up, 32 undertaken with the consent of IPMC and patients were patients (57%) changed to borderline, and 5 patients unlikely to suffer any burden or harm. Only anonymous (9%) changed to normal. data were collected for this audit and stored at the gen- Table 3 shows a seasonal variation of when the 25- eral practice. OHD tests were taken in 266 patients with 34% taken in autumn, 14% in winter, 20% in spring, and 31% in sum- Results mer. The variation among the 89 patients who had low 25-OHD differed with 31% taken in autumn, 22% in Part 1 of Audit Of 955 patients audited, 486 (51%) had a Medicare winter, 33% in spring, and 13% in summer. funded Health Assessment and significantly more women (54%) had this assessment than men (46%) (316 Part 2 of Audit women versus 170 men, Pearson Chi-Square = 6.57, df Of the 584 patients who were sent general health advice = 1, p = 0.010). Among the 469 (49%) patients who did in the mail, 50% were randomly selected to receive addi- not have a Medicare funded Health Assessment, signifi- tional written information about vitamin D, and 50% cantly more men (54%) did not have this assessment were not. Part 2 Audit resulted in an additional 115 than women (46%) (202 men versus 267 women, Pear- patients having a Health Assessment (20% of total). son Chi-Square = 6.57, df = 1, p = 0.010). There was no difference in the proportion of patients Table 1 Gender comparison of weight, waist, BMI, Activity score, and serum 25-hydroxyvitamin D (25-OHD) levels in 955 patients aged 45 to 49 years in one general practice in Canberra Variable Male Female t test P value Minimum Maximum Mean SD Minimum Maximum Mean SD Weight (Kilograms) 55 125 90.0 14.2 47 143 78.34 17.8 8.5 0.000 Waist (centimetres) 72 136 96.9 12.6 26 127 86.88 14.2 8.3 0.000 BMI* score 20 43 27.4 4.4 21 53 28.08 6.7 0.1 0.471 Activity score 0 8 3.9 2.0 0 10 3.09 2.2 - 0.500* 25-OHD level (nmol/l) 10 141 74.0 28.8 12 228 60.3 26.3 3.8 0.000 BMI = Body mas index (kg/m ) Reference range BMI of ≥ 25 conveys increased risk [1] Waist reference range ≥ 94 cm in males and ≥ 80 cm in females conveys increased risk [1] * Mann-Whitney U test Kljakovic et al. Asia Pacific Family Medicine 2012, 11:3 Page 3 of 4 http://www.apfmj.com/content/11/1/3 Table 2 The number of patients who had initial and six-month follow-up serum 25-hydroxyvitamin D (25-OHD) taken as part of their Health Assessment in general practice n = 266 patients Number of patients with initial 25-OHD levels* % Follow up 25-OHD levels at six months Low Borderline Normal Total followed % Low 89 33.5% 19 32 5 56 63% Borderline 109 41% 1 1 1 3 3% Normal 68 26% - - - 0 0% *Low 25-hydroxyvitamin D = < 51 nmol/l, Borderline 25-hydroxyvitamin D = 51-79 nmol/l, Normal 25-hydroxyvitamin D = 80+ nmol/l who had a Health Assessment and received specific response to high temperatures in the ACT in the sum- written information about vitamin D compared to those mer months. who did not (21% versus 18%, Pearson Chi-Square = The audit revealed a gender imbalance: Women were 0.592, df = 1, p = 0.442). more likely to have a health assessment than men and consequently were more likely to have a test. However, Discussion women were also found to have significantly lower 25- This audit revealed that after three years of work IPMC OHD level than men. Furthermore, men were signifi- had attempted a Health Assessment of the vitamin D cantly heavier and had larger waists than women, but status in 51% of patients aged 45 to 49 years. Although no difference in BMI or activity scores. These differ- half of these patients had their weight measured, only ences suggest that men and women need different prac- 28% had a test to measure 25-OHD. tice policies for health promotion. The audit revealed a bias towards testing patients who The audit demonstrated that sending uninvited health had low or borderline 25-OHD. This suggests that the promotion information to patients had no effect on sub- 25-OHD test was not used as a screening tool; rather it sequent attendance for health promotion in this prac- was used for case finding. Knowledge of a patient’slow tice. New health promotion strategies are needed. For 25-OHD appeared to have little impact on changing the example, sending a newsletter to the whole practice patient’s level. Only 8% of such patients were subse- population, or working in conjunction with the local quently shown to revert back to normal levels. media, might stimulate more people to consider the The overall mean 25-OHD level (74.0 nmol/l) found relationship between vitamin D and the amount of sun- in this audit was similar to the 76.9 nmol/l mean level light exposure they experience. The RACGP guidelines for preventive activities in general practice list the stra- found in a group of Adelaide residents[4] and higher than the 56.8 nmol/l mean level found in a recent study tegies that Australian general practice might undertake of adult Aboriginal Australians[5]. Furthermore, the for health promotion and mentions vitamin D [1]. The audit confirmed the known seasonal variation in 25- guidelines do not mention how practices might vary OHD [5] by finding a high proportion of 25-OHD tests their strategies in response to specific characteristics taken in summer compared to other seasons and a com- such as the gender profile of the general practice. paratively low proportion of patients with low levels of The limitations of this clinical audit include the bias of 25-OHD in summer. In our audit, we did not measure using only one general practice, the non-random selec- the amount of time patients spent outside. Therefore we tion of patients, the local laboratory determined the nor- can only speculate that the paradoxical relationship mal serum 25-OHD reference range, and the between a high proportion of testing undertaken in measurement error inherent in undertaking an audit. (In summer and a low proportion of patients with low levels Australian general practice patients may go elsewhere to of 25-OHD in summer is a consequence of patient manage their low 25-OHD and there are limited behaviour - perhaps patients spend less time outside in mechanisms to ensure patients comply on follow up of Table 3 Seasonal variation of serum 25-hydroxyvitaminin D (25-OHD) in 266 patients from one general practice in Canberra Number Season n Mean 25-OHD < 51 nmol/l 51-79 nmol/l 80+ nmol/l level (nmol/l) Autumn 91 66.1 28 42 21 Winter 38 54.7 20 11 7 Spring 54 53.8 29 18 7 Summer 83 73.7 12 38 33 Kljakovic et al. Asia Pacific Family Medicine 2012, 11:3 Page 4 of 4 http://www.apfmj.com/content/11/1/3 low-test results). Finally we did not measure the amount of sunlight exposure in patients. Insummary, aconsiderableamountofworkwas undertaken by IPMC over three years resulting in half the target group of patients receiving health promotion, just over a quarter had the appropriate blood test, and none were influenced by uninvited written health infor- mation on vitamin D. The audit taught IPMC that men and women need different policies for health promotion on the association between 25-OHD levels and time spent outside in summer. Authorship MK conceived of the study, participated in its design and statistical analysis, and helped to draft the manu- script. CD coordinated with IPMC and collected all data. RS and DS supervised CD and helped with coordi- nating with IPMC. All authors read and approved the final manuscript. Abbreviations GP: general practitioner; IPMC: Isabella Plains Medical Centre; 25-OHD: 25- hydroxyvitamin D; RACGP: Royal Australian College of General Practitioners. Acknowledgements The authors would like to thank the Isabella Plains Medical Centre for giving consent to undertake this clinical audit. Author details Academic Unit of General Practice in the School of General Practice, Rural and Indigenous Health, at the Australian National University Medical School, PO Box 11 Woden, ACT 2606 Canberra, Australia. Practice nurse at Isabella Plains Medical Centre, 9 Arakoon Crescent Isabella Plains, ACT 2905 Canberra, Australia. General practitioner at Isabella Plains Medical Centre, 9 Arakoon Crescent, Isabella Plains, ACT 2905 Canberra, Australia. General practitioner at Isabella Plains Medical Centre, 9 Arakoon Crescent, Isabella Plains, ACT 2905 Canberra, Australia. Competing interests The authors declare that they have no competing interests. Received: 19 January 2012 Accepted: 2 April 2012 Published: 2 April 2012 References 1. The Royal Australian College of General Practitioners: Guidelines for preventive activities in general practice (7th Edition) Melbourne: The Royal Australian College of General Practitioners; 2009. 2. Cancer Council: Vitamin D and sun exposure Cancer Council Australia: Sydney; 2008. 3. National Health and Medical Research Council: National Statement on Submit your next manuscript to BioMed Central Ethical Conduct in Human Research Commonwealth of Australia: Canberra; and take full advantage of: 4. Morris HA, Morrison GW, Burr M, Thomas DW, Nordin BE: Vitamin D and • Convenient online submission femoral neck fractures in elderly South Australian women. Med J Aust 1984, 140(9):519-21. • Thorough peer review 5. Vanlint SJ, Morris HA, Newbury JW, Crockett AJ: Vitamin D insufficiency in • No space constraints or color figure charges Aboriginal Australians. Med J Aust 2011, 194(3):131-4. • Immediate publication on acceptance doi:10.1186/1447-056X-11-3 • Inclusion in PubMed, CAS, Scopus and Google Scholar Cite this article as: Kljakovic et al.: Clinical audit of health promotion of vitamin D in one general practice. Asia Pacific Family Medicine 2012 11:3. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Clinical audit of health promotion of vitamin D in one general practice

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Springer Journals
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Copyright © 2012 by Kljakovic et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: The clinical audit of vitamin D health promotion in one Australian general practice was undertaken by measuring health service use and serum 25-hydroxyvitamin D levels in 995 patients aged 45 to 49 years. Findings: Over 3 years, 486 (51%) patients had a Medicare funded Health Assessment. More women (54%) were assessed than men (46%) p = 0.010. Mean 25-OHD was higher for men (70.0 nmol/l) than women (60.3 nmol/l) p < 0.001. More patients had their weight measured (50%) than 25-OHD tested (28%). Among 266 patients who had a 25-OHD test, 68 (26%) had normal levels 80+ nmol/l, 109 (41%) were borderline 51-79 nmol/l, and 89 (33%) were low < 51 nmol/l. Mean 25-OHD was higher in summer (73.7 nmol/l) than winter (54.7 nmol/l) p < 0.001. Sending uninvited written information about 25-OHD had no effect on patients’ subsequent attendance. Conclusions: Health promotion information about vitamin D was provided to 50% of a targeted group of patients over a one-year period. Provision of this information had no effect on the uptake rates of an invitation to attend for a general health assessment. Keywords: Vitamin D, Health promotion, General practice, Clinical audit Findings criteria included all patients registered with IPMC elec- The RACGP (Royal Australian College of General Prac- tronic health records and eligible for a Health Assess- titioner) Red Book provides specific recommendations ment funded through Medicare Item Number 717 (A on vitamin D and sunlight exposure in health promo- policy introduced by the commonwealth government on tion[1]. This clinical audit was initiated when one GP 1st November 2006 meant for patients aged 45 to 49 (general practitioner) at the IPMC (Isabella Plains Medi- years to consult for reasons of health promotion in gen- cal Centre) observed that many patients appeared to be eral practice). deficient in serum vitamin D. The aim of this clinical audit was to evaluate how IPMC managed its health Part 1 Audit promotion surrounding vitamin D. described the characteristics of patients aged 45-49 years who consulted the practice under Item Number 717 Method between November 2006 and October 2008. Practice setting IPMC has 10 full-time equivalent GPs, four practice Part 2 Audit nurses, and five allied health workers who care for a measured the impact of written advice on patients who practice population of 19,417 patients. The audit consulted IPMC for health promotion between October occurred in two parts over a three-year period between 2008 and December 2009. Patients were sent a letter November 2006 and December 2009. The selection inviting them to consult with IPMC. Half were ran- domly selected to receive the invitation only, the other half received the invitation letter as well as specific * Correspondence: Marjan.kljakovic@anu.edu.au Academic Unit of General Practice in the School of General Practice, Rural information contained in a Cancer cosmetics pamphlet and Indigenous Health, at the Australian National University Medical School, [2] on the role of vitamin D and how to obtain a blood PO Box 11 Woden, ACT 2606 Canberra, Australia test. Full list of author information is available at the end of the article © 2012 Kljakovic et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kljakovic et al. Asia Pacific Family Medicine 2012, 11:3 Page 2 of 4 http://www.apfmj.com/content/11/1/3 The variables measured in this audit were the number There were 474 patients (50%) who had their weight of people who attended IPMC under Item Number 717 measured; 473 (50%) had their BMI score calculated; and their serum 25-OHD (25-hydroxyvitamin D) levels, 427 (45%) had their waist measured; 432 (45%) had the serum biomarker of vitamin D. Patients who are their activity score measured; And 266 (28%) had a 25- subsequently found to have a low 25-OHD level are OHD test. Table 1 shows males were significantly hea- routinely retested at six months intervals. The local vier and had larger waists than women, but no differ- laboratory determined the normal range for 25-OHD ence in BMI or activity scores than women. Women was 51 nmol/l to 140 nmol/l: A low level was defined as had significantly lower 25-OHD than men, even though more women had a 25-OHD test taken than men (32% < 51 nmol/l 25-OHD, 51-79 nmol/l was defined border- line, and 80+ nmol/l was defined normal. The season in versus 21%, Pearson Chi-Square = 13.28, df = 1, p < which the test was taken was also measured). Other 0.001). variables included gender, weight, BMI, waist circumfer- Among 486 patients who had a Health Assessment, ence, and the level of activity patients reported they per- 220 patients (45%) did not have a 25-OHD test, 207 formed in daily life. (Ranked on a 14-point Likert scale patients (43%) had one test, 46 patients (9.5%) had two where 0-points was no daily physical activity to 14- 25-OHD tests, and 13 patients (3%) had three 25-OHD points was 60 minutes of activity daily at a very strenu- tests. ous level). Among the 266 patients who had 25-OHD tests, 89 Data were coded in excel and analysed in PASW Sta- patients (33%) had low 25-OHD of < 51 nmol/l, 109 tistics 18™ comparing differences between categories patients (41%) had borderline 25-OHD of 51-79 nmol/l, using the non-parametric chi squared test where and 68 patients (26%) had normal 25-OHD of 80+ appropriate. nmol/l. Table 2 shows that 59 patients (66%) had a fol- Ethical approval was not sought for this audit because low up 25-OHD test six months later. Among the 56 it met the National Health and Medical Research Coun- patients who had low 25-OHD at initial assessment, 19 cil’s criteria for exemption [3], namely the audit was patients (34%) remained at a low level at follow up, 32 undertaken with the consent of IPMC and patients were patients (57%) changed to borderline, and 5 patients unlikely to suffer any burden or harm. Only anonymous (9%) changed to normal. data were collected for this audit and stored at the gen- Table 3 shows a seasonal variation of when the 25- eral practice. OHD tests were taken in 266 patients with 34% taken in autumn, 14% in winter, 20% in spring, and 31% in sum- Results mer. The variation among the 89 patients who had low 25-OHD differed with 31% taken in autumn, 22% in Part 1 of Audit Of 955 patients audited, 486 (51%) had a Medicare winter, 33% in spring, and 13% in summer. funded Health Assessment and significantly more women (54%) had this assessment than men (46%) (316 Part 2 of Audit women versus 170 men, Pearson Chi-Square = 6.57, df Of the 584 patients who were sent general health advice = 1, p = 0.010). Among the 469 (49%) patients who did in the mail, 50% were randomly selected to receive addi- not have a Medicare funded Health Assessment, signifi- tional written information about vitamin D, and 50% cantly more men (54%) did not have this assessment were not. Part 2 Audit resulted in an additional 115 than women (46%) (202 men versus 267 women, Pear- patients having a Health Assessment (20% of total). son Chi-Square = 6.57, df = 1, p = 0.010). There was no difference in the proportion of patients Table 1 Gender comparison of weight, waist, BMI, Activity score, and serum 25-hydroxyvitamin D (25-OHD) levels in 955 patients aged 45 to 49 years in one general practice in Canberra Variable Male Female t test P value Minimum Maximum Mean SD Minimum Maximum Mean SD Weight (Kilograms) 55 125 90.0 14.2 47 143 78.34 17.8 8.5 0.000 Waist (centimetres) 72 136 96.9 12.6 26 127 86.88 14.2 8.3 0.000 BMI* score 20 43 27.4 4.4 21 53 28.08 6.7 0.1 0.471 Activity score 0 8 3.9 2.0 0 10 3.09 2.2 - 0.500* 25-OHD level (nmol/l) 10 141 74.0 28.8 12 228 60.3 26.3 3.8 0.000 BMI = Body mas index (kg/m ) Reference range BMI of ≥ 25 conveys increased risk [1] Waist reference range ≥ 94 cm in males and ≥ 80 cm in females conveys increased risk [1] * Mann-Whitney U test Kljakovic et al. Asia Pacific Family Medicine 2012, 11:3 Page 3 of 4 http://www.apfmj.com/content/11/1/3 Table 2 The number of patients who had initial and six-month follow-up serum 25-hydroxyvitamin D (25-OHD) taken as part of their Health Assessment in general practice n = 266 patients Number of patients with initial 25-OHD levels* % Follow up 25-OHD levels at six months Low Borderline Normal Total followed % Low 89 33.5% 19 32 5 56 63% Borderline 109 41% 1 1 1 3 3% Normal 68 26% - - - 0 0% *Low 25-hydroxyvitamin D = < 51 nmol/l, Borderline 25-hydroxyvitamin D = 51-79 nmol/l, Normal 25-hydroxyvitamin D = 80+ nmol/l who had a Health Assessment and received specific response to high temperatures in the ACT in the sum- written information about vitamin D compared to those mer months. who did not (21% versus 18%, Pearson Chi-Square = The audit revealed a gender imbalance: Women were 0.592, df = 1, p = 0.442). more likely to have a health assessment than men and consequently were more likely to have a test. However, Discussion women were also found to have significantly lower 25- This audit revealed that after three years of work IPMC OHD level than men. Furthermore, men were signifi- had attempted a Health Assessment of the vitamin D cantly heavier and had larger waists than women, but status in 51% of patients aged 45 to 49 years. Although no difference in BMI or activity scores. These differ- half of these patients had their weight measured, only ences suggest that men and women need different prac- 28% had a test to measure 25-OHD. tice policies for health promotion. The audit revealed a bias towards testing patients who The audit demonstrated that sending uninvited health had low or borderline 25-OHD. This suggests that the promotion information to patients had no effect on sub- 25-OHD test was not used as a screening tool; rather it sequent attendance for health promotion in this prac- was used for case finding. Knowledge of a patient’slow tice. New health promotion strategies are needed. For 25-OHD appeared to have little impact on changing the example, sending a newsletter to the whole practice patient’s level. Only 8% of such patients were subse- population, or working in conjunction with the local quently shown to revert back to normal levels. media, might stimulate more people to consider the The overall mean 25-OHD level (74.0 nmol/l) found relationship between vitamin D and the amount of sun- in this audit was similar to the 76.9 nmol/l mean level light exposure they experience. The RACGP guidelines for preventive activities in general practice list the stra- found in a group of Adelaide residents[4] and higher than the 56.8 nmol/l mean level found in a recent study tegies that Australian general practice might undertake of adult Aboriginal Australians[5]. Furthermore, the for health promotion and mentions vitamin D [1]. The audit confirmed the known seasonal variation in 25- guidelines do not mention how practices might vary OHD [5] by finding a high proportion of 25-OHD tests their strategies in response to specific characteristics taken in summer compared to other seasons and a com- such as the gender profile of the general practice. paratively low proportion of patients with low levels of The limitations of this clinical audit include the bias of 25-OHD in summer. In our audit, we did not measure using only one general practice, the non-random selec- the amount of time patients spent outside. Therefore we tion of patients, the local laboratory determined the nor- can only speculate that the paradoxical relationship mal serum 25-OHD reference range, and the between a high proportion of testing undertaken in measurement error inherent in undertaking an audit. (In summer and a low proportion of patients with low levels Australian general practice patients may go elsewhere to of 25-OHD in summer is a consequence of patient manage their low 25-OHD and there are limited behaviour - perhaps patients spend less time outside in mechanisms to ensure patients comply on follow up of Table 3 Seasonal variation of serum 25-hydroxyvitaminin D (25-OHD) in 266 patients from one general practice in Canberra Number Season n Mean 25-OHD < 51 nmol/l 51-79 nmol/l 80+ nmol/l level (nmol/l) Autumn 91 66.1 28 42 21 Winter 38 54.7 20 11 7 Spring 54 53.8 29 18 7 Summer 83 73.7 12 38 33 Kljakovic et al. Asia Pacific Family Medicine 2012, 11:3 Page 4 of 4 http://www.apfmj.com/content/11/1/3 low-test results). Finally we did not measure the amount of sunlight exposure in patients. Insummary, aconsiderableamountofworkwas undertaken by IPMC over three years resulting in half the target group of patients receiving health promotion, just over a quarter had the appropriate blood test, and none were influenced by uninvited written health infor- mation on vitamin D. The audit taught IPMC that men and women need different policies for health promotion on the association between 25-OHD levels and time spent outside in summer. Authorship MK conceived of the study, participated in its design and statistical analysis, and helped to draft the manu- script. CD coordinated with IPMC and collected all data. RS and DS supervised CD and helped with coordi- nating with IPMC. All authors read and approved the final manuscript. Abbreviations GP: general practitioner; IPMC: Isabella Plains Medical Centre; 25-OHD: 25- hydroxyvitamin D; RACGP: Royal Australian College of General Practitioners. Acknowledgements The authors would like to thank the Isabella Plains Medical Centre for giving consent to undertake this clinical audit. Author details Academic Unit of General Practice in the School of General Practice, Rural and Indigenous Health, at the Australian National University Medical School, PO Box 11 Woden, ACT 2606 Canberra, Australia. Practice nurse at Isabella Plains Medical Centre, 9 Arakoon Crescent Isabella Plains, ACT 2905 Canberra, Australia. General practitioner at Isabella Plains Medical Centre, 9 Arakoon Crescent, Isabella Plains, ACT 2905 Canberra, Australia. General practitioner at Isabella Plains Medical Centre, 9 Arakoon Crescent, Isabella Plains, ACT 2905 Canberra, Australia. Competing interests The authors declare that they have no competing interests. Received: 19 January 2012 Accepted: 2 April 2012 Published: 2 April 2012 References 1. The Royal Australian College of General Practitioners: Guidelines for preventive activities in general practice (7th Edition) Melbourne: The Royal Australian College of General Practitioners; 2009. 2. Cancer Council: Vitamin D and sun exposure Cancer Council Australia: Sydney; 2008. 3. National Health and Medical Research Council: National Statement on Submit your next manuscript to BioMed Central Ethical Conduct in Human Research Commonwealth of Australia: Canberra; and take full advantage of: 4. Morris HA, Morrison GW, Burr M, Thomas DW, Nordin BE: Vitamin D and • Convenient online submission femoral neck fractures in elderly South Australian women. Med J Aust 1984, 140(9):519-21. • Thorough peer review 5. Vanlint SJ, Morris HA, Newbury JW, Crockett AJ: Vitamin D insufficiency in • No space constraints or color figure charges Aboriginal Australians. Med J Aust 2011, 194(3):131-4. • Immediate publication on acceptance doi:10.1186/1447-056X-11-3 • Inclusion in PubMed, CAS, Scopus and Google Scholar Cite this article as: Kljakovic et al.: Clinical audit of health promotion of vitamin D in one general practice. Asia Pacific Family Medicine 2012 11:3. • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

Asia Pacific Family MedicineSpringer Journals

Published: Apr 2, 2012

References