University at Buffalo Libraries ◆ InterLibrary Loan, Lending

234 Lockwood Library ◆ Buffalo, NY 14260

(716) 645-2812 ◆ buflend@buffalo.edu

ILL#_________

NOTICE This material may be protected

by copyright law (Title 17 U.S. Code).

Please contact us if you require a resend.

http://qhr.sagepub.com/Qualitative Health Research

http://qhr.sagepub.com/content/early/2014/10/07/1049732314554100The online version of this article can be found at:

 DOI: 10.1177/1049732314554100

published online 7 October 2014Qual Health ResJohn W. Epling, Emily M. Mader, Carrie A. Roseamelia and Christopher P. Morley

Emerging Practice Concerning Vitamin D in Primary Care  

Published by:

http://www.sagepublications.com

can be found at:Qualitative Health ResearchAdditional services and information for    

  http://qhr.sagepub.com/cgi/alertsEmail Alerts:

 

http://qhr.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Oct 7, 2014OnlineFirst Version of Record >>

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

Qualitative Health Research 1 –8© The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1049732314554100qhr.sagepub.com

Evidence for Practice

Testing for and treating low vitamin D levels (“hypovita-minosis D”) has become a common practice as both workup for certain medical conditions and symptoms and as part of routine health maintenance. Shahangian et al. noted that although overall outpatient laboratory reim-bursement volumes from Medicare Part B for nutritional indicators rose by approximately 50% from 2000 to 2010, vitamin D reimbursement volumes increased 80%, with the majority of the increase occurring since 2005 (Shahangian, Alspach, Astles, Yesupriya, & Dettwyler, 2014). Concurrently, interest in vitamin D within the gen-eral population is also rising, with an apparent four-fold increase in searches for information about vitamin D in Google Trends (trends.google.com; http://bit.ly/1gxLgQo) between 2005 and 2013.

Vitamin D is acknowledged to be important in infant development as well as in the maintenance of bone health (Avenell, Gillespie, Gillespie, & O’Connell, 2009; Institute of Medicine, 2011; Kulie, Groff, Redmer, Hounshell, & Schrager, 2009), and has possible associa-tions with cardiovascular disease (Motiwala & Wang, 2011; Wang et al., 2012), cancer (Kulie et al., 2009; Pilz et al., 2013; Yin et al., 2009), general fatigue, and other diseases (Cao et al., 2013; Diaz, Mainous, Carek, Wessell, & Everett, 2009; Stockton, Mengersen, Paratz, Kandiah, & Bennell, 2011). However, there is chaotic and sometimes conflicting knowledge about diagnosing hypovitaminosis

D and the methods for supplementing or replacing vitamin D (Binkley & Wiebe, 2013; Holick et al., 2011).

No guidelines on vitamin D testing and management in primary care had been published at the onset of the study detailed in this article. Even now, a recent compre-hensive, systematic review by the Institute of Medicine (2011)—which recommends no screening for most of the population, and only modest universal supplementa-tion—seems to have received very little attention in pri-mary care. In the absence of well-known, consistent guidelines on the subject, primary care providers face uncertainty in the management and testing of vitamin D among their patients. The recently published results of a qualitative study of uncertainty management by Bennett, Frisby, Young, and Murray (2014). indicate that the uncertainty surrounding vitamin D negatively impacts communication between patients and providers on testing and treatment. Although Bennett et al. offered important information regarding the impact of clinical uncertainty

554100QHRXXX10.1177/1049732314554100Qualitative Health ResearchEpling et al.research-article2014

1State University of New York Upstate Medical University, Syracuse, New York, USA

Corresponding Author:John W. Epling, Department of Family Medicine, SUNY Upstate Medical University, 475 Irving Ave, Ste. 200, Syracuse, NY 13210, USA. Email: eplingj@upstate.edu

Emerging Practice Concerning Vitamin D in Primary Care

John W. Epling1, Emily M. Mader1, Carrie A. Roseamelia1, and Christopher P. Morley1

AbstractThe establishment of practice patterns concerning the diagnosis and management of hypovitaminosis D seems to be heterogeneous among primary care physicians. We conducted a qualitative study to explore the emerging practices among primary care providers regarding screening and treatment for hypovitaminosis D, as well as factors that influence practice patterns. Trained researchers facilitated focus groups among primary care providers. We followed a grounded theory approach to transcript coding and analysis using ATLAS.ti analysis software. Testing or screening for hypovitaminosis D and subsequent replacement or supplementation practices varied among participants. Emerging practice concerning vitamin D appears to be constructed and reinforced by patient demand; incidental reading; brief, purposeful research; conversations with colleagues; results of consultations by specialists; and more patient demand. A multifaceted approach to promoting guideline adherence will be required to influence this practice.

Keywordsepistemology; focus groups; grounded theory; health care, primary; health information seeking; knowledge construction; knowledge transfer; relationships

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

2 Qualitative Health Research

on patient and physician behaviors, questions remain regarding the formation of physician practice patterns as they relate to vitamin D testing and treatment.

It is clear that primary care providers, including physi-cians and mid-level providers, are establishing practice patterns concerning the diagnosis and management of hypovitaminosis D. These patterns, however, seem to be notably heterogeneous, and the sources of information used to establish these patterns remain unclear. This situa-tion has created an opportunity to add to our understand-ing of emerging practice in primary care in the absence of authoritative guidelines. At a convocation of the Studying-Acting-Learning-Teaching practice-based research net-work (SALT-Net) in 2008, participants indicated that questions regarding vitamin D testing and treatment required exploration. In response, we conducted a qualita-tive study to investigate emerging practices among pri-mary care providers within SALT-Net regarding screening and treatment for hypovitaminosis D.

Methods

Our goal was to conduct a qualitative exploratory study of the attitudes and practices of primary care providers in our region around the diagnosis and management of hypovita-minosis D, as well as to identify the common sources of information about vitamin D diagnosis and management and the factors that might drive hypovitaminosis D screen-ing and treatment practice. We utilized focus groups facili-tated by trained researchers (third and fourth authors Roseamelia and Morley) for this exploratory study. The initial focus group was conducted at a continuing medical education (CME) event, and the remaining focus groups were conducted at the offices of participating practices.

Study Participants

SALT-Net consists of more than 200 affiliates who pri-marily serve as preceptors, community faculty, commu-nity residency affiliates, or other regional partnerships. SALT-Net is geographically located in central New York State and covers a broad area bordered to the south by Pennsylvania and to the north by Lake Ontario and the Saint Lawrence Seaway, and extends roughly 75 miles to the east and west from Syracuse, New York. Primary care providers from SALT-Net were recruited by email and mail invitations. Participants included prescribing clini-cians (physicians, nurse practitioners, physician assis-tants); by definition, all participants were adults.

Human Subjects Protection

We submitted the protocol for the described study to the Institutional Review Board of SUNY Upstate Medical

University, and were granted an exemption from review. At the outset of each focus group session, the focus group facilitator explained the purpose of the study, the focus group procedures, and privacy protections. Each partici-pant then gave written and signed informed consent to participate. Incentives to participate included a time-appropriate meal served during the focus group and a lec-ture delivered by a physician on the study team (first author Epling) immediately following the focus group on current vitamin D guidelines and recommendations. Those receiving the lecture were eligible to receive CME credit. All notes and transcripts omitted names and other identifying information, allowing the study data to be anonymized.

Data Collection & Analysis

After providing informed consent, a facilitator (Roseamelia or Morley) led a focus group discussion based on a set of guide questions. The facilitators were not clinically trained and were naïve to the practice pat-terns being discussed; this allowed the facilitators to be objective in guiding the focus group discussions. Discussion was encouraged from all participants, and the sessions were recorded and supplemented by field notes when possible.

Initial and subsequent analysis included open coding of the transcript data with identification of emergent themes. We followed a predominantly grounded theory approach (Pope, Ziebland, & Mays, 2000), but one author (Epling) was influenced (Cohen & Crabtree, 2008) by work in evidence-based medicine (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996) and information mastery theory (Slawson & Shaughnessy, 1999), as well as theories of personal and organizational change. All study team members performed an ongoing review of focus group notes, which facilitated the exploration of emerging themes in subsequent focus group sessions. Focus groups were constituted until data saturation became apparent.

We created transcripts from the focus group record-ings. Two authors (Epling and Mader) independently conducted initial coding of two transcripts, followed by a joint review and consolidation of the code list. The same authors then coded all of the transcripts, with subsequent review of these codes by the other authors (Roseamelia and Morley). We used ATLAS.ti analytic software to per-form the coding and analysis (Scientific Software Development, 2014).

Results

A total of 42 participants participated in five focus group sessions. The majority of participants were practicing

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

Epling et al. 3

physicians, although some focus groups included physi-cian assistants and nurse practitioners. One medical stu-dent and one registered nurse were present for the focus group session and CME presentation in their practice, for educational purposes.

There was variability in how the participants identi-fied patients as being within the optimal range for vitamin D levels in serum. The minimum level of acceptable vita-min D generally centered around 30 ng/ml or above; however, several individuals mentioned optimal ranges of 40 to 60 ng/ml, 50 to 70 ng/ml, or any number up to 100 ng/ml. When discussing toxicity of vitamin D, the general conclusion was that numbers above 100 ng/ml signify toxicity. It is important to note, though, that some individuals described the toxic range as above 50 ng/ml, while others admitted that they had “lost a lot of fear” over vitamin D toxicity and did not specify a toxic level among their patients. There was also notable variability in how participants identified patients as insufficient or deficient in vitamin D levels. This range generally began with insufficiency noted at below 30 ng/ml, although the point at which a patient transitioned from insufficiency to deficiency varied from between 20 to 15 ng/ml, and was even as low as 10 ng/ml for some participants.

Participants reported a wide range of treatment strategies and dosage levels for low vitamin D. Participants who were more concerned over the threat of vitamin D toxicity or other unknown impacts of treatment limited the daily intake of vitamin D to a range of 800 to 2,000 international units (IUs) per day. Other participants reported that the level of daily or weekly intake of vitamin D was dependent on the patient’s original vitamin D level. For those needing replacement (i.e., those who were deemed deficient), the levels prescribed could be as high as 50,000 IUs per week; once levels reached the optimum range, the patient would be placed on a maintenance dose ranging from 2,000 to 12,000 IUs per day.

When seeking information on vitamin D management, the majority of participants referred to discussions with colleagues—usually within their own practice—as a means by which they gained information on vitamin D. Many of the participants also cited point-of-care resources, such as UpToDate and Essential Evidence Plus, as well as literature and guideline resources, including PubMed, The Cochrane Library, the United States Preventive Services Task Force Recommendations, and the National Guideline Clearinghouse. However, it is important to note that these resources were often listed within hypothetical contexts and did not necessarily reflect actions taken in obtaining information on vitamin D.

Several of the participants reported that at the time of the focus group, they had not actively researched infor-mation on vitamin D. Furthermore, several of the

participants who mentioned discourses with colleagues about vitamin D were referring to events that occurred several years prior to the focus group. Thus, it appears that the members of the focus groups were not actively seeking information regarding vitamin D guidelines and practices, despite knowing the appropriate resources to obtain this information. Beyond these general descrip-tions of participant behaviors, we identified four salient themes about participant perceptions and practices regarding vitamin D during analysis of the focus group transcripts.

The Primary Driver of Demand is the Patient

A small group of participants (usually one per focus group) mentioned integrating vitamin D testing into rou-tine patient physicals. These individuals tended to be pro-ponents of vitamin D testing and treatment in general, citing patient satisfaction with vitamin D supplementa-tion. However, the participants overwhelmingly reported that the primary source of demand to conduct vitamin D testing originated with the patient. Participants reported that in most scenarios, their patients would specifically request vitamin D testing without prompting; a few par-ticipants reported that some of their patients would request testing while discussing symptoms of general fatigue or joint pain. Several participants reported that they usually performed this patient-requested vitamin D testing because they “[didn’t] really see any harm in doing it.”

The predominant source of patient information on vitamin D was the media, including radio, magazines, and television programming. In particular, the partici-pants focused on television personalities, including Dr. Mehmet Oz and Oprah Winfrey, as the primary media influences on patient information regarding vitamin D, with one participant mentioning that, “Ninety percent of mine say Dr. Oz.” The participants frequently expressed exasperation at this significant media influence on patient demand.

Participants also brought up the influence of other medical professionals on patient demand, particularly specialists within endocrinology and neurology. Some participants mentioned that the recommendations or treatments for vitamin D provided by these outside spe-cialists conflicted with their patient care plans. Several participants felt that this “erratic behavior” within and between practices often left patients feeling confused about their own care. A small number of participants also reported that their patients were influenced by the experi-ences of friends and family in their knowledge about and request for vitamin D testing and treatment. Table 1 dis-plays the breakdown of subthemes and exemplar quotes for Theme 1.

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

4 Qualitative Health Research

Reflexive Acceptance of Patient Demand

A number of participants seemed to reflexively accept the demand for vitamin D into regular patient care without conducting additional investigation into the topic. This group of participants often reported performing vitamin D tests to ease the “patient’s peace of mind,” and rarely conducted follow-up testing for those patients taking sup-plements. In fact, several participants reported that they routinely recommended that patients take an over-the-counter supplement for vitamin D rather than going through the process of testing and obtaining laboratory reports on vitamin D levels, if the topic was brought up during an office visit. This group of participants also tended to default to the metrics provided by laboratory services rather than consult guidelines in designating patients as vitamin D deficient.

This reflexive acceptance stemmed largely from the perception that vitamin D testing and supplementation are benign activities that present no real risk of harm to the patient. A secondary influence on this pattern of testing and treatment stemmed from the barriers of insurance reimbursement and medication coverage. Several partici-pants reported issues in finding appropriate billing codes for vitamin D screening, particularly with Medicare. One participant reported that he was instructed by the insur-ance company to “put down that she is hypothyroid” so he could be appropriately reimbursed for the vitamin D test of a patient; this experience of using alternative coding mechanisms for reimbursement was mirrored by several participants across the focus groups. Additionally, patient feedback on the cost of testing and prescription medica-tion led several participants to simply recommend over-the-counter supplementation outside of formal testing and

deficiency diagnosis. Table 2 displays the breakdown of subthemes and exemplar quotes for Theme 2.

Incorporation Into Patient Care as a Diagnostic Tool

Other participants incorporated vitamin D testing and treatment into patient-specific diagnostic activities and care management. These participants would base the need for testing on individual patient histories. The most frequently cited patient groups receiving this focus included those with osteoporosis or at high risk of falling, those with autoimmune diseases, those with digestive or malabsorption disorders, those with mood disorders, and those complaining of fatigue or muscle aches. One par-ticipant stated, “If people have any symptoms that may make me think of vitamin D deficiency or insufficiency, that’s when I actually screen.” This group of participants frequently made the distinction between screening and diagnosis, stating that their vitamin D testing activities often fell within the lines of diagnostic testing rather than across-the-board screening of patients. Treatment of these patients was then often dictated by symptom com-plex, with the goal of having “some symptom benefit and not in the toxic range.” Table 3 displays the breakdown of subthemes and exemplar quotes for Theme 3.

Doubt

A substantial number of participants viewed the patient-driven demand for vitamin D testing and treatment with skepticism. Comments made by these physicians were marked by a sense of caution because of the uncertainty

Table 1. Theme 1: The Primary Driver of Demand is the Patient.

Component Theme Subcategory Exemplar Quotation

Provider Championing

Provider Pro-Vitamin D Bias

“Middle aged and beyond women, I just put them on vitamin D anyway, because I think it is a good idea. So, I don’t bother doing a screening level on them.”

Patient Satisfaction

“And, as far as outcomes, based on supplementation, a fair number of patients have had very positive symptom improvements.”

Direct Patient Demand

Media Influence “You know Oprah did a show on it.”“Somebody on television, Dr. Oz, talked about it.”“I think it’s on the radio a lot. There must be magazines that they

read, too.”Specialist

Influence“It’s a plethora of, ‘I’m a vitamin D mess.’ And they usually come from

the endocrinologist, or you know, who ran a vitamin D level.”“What I’ve actually heard is it’s not a national debate; it’s between

individual physicians. People walking into your office sometimes getting different info [information] from another physician.”

Social Influence “And everybody in my practice says, ‘Oh yeah, my mother is now on vitamin D.’ ‘My brother went to his doctor, and he is vitamin D deficient.’”

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

Epling et al. 5

surrounding the effects of vitamin D supplementation. The lack of evidence surrounding the indications for and effects of vitamin D treatment played a direct role in how these participants approached the issue with their patients. The majority of participants expressing this skepticism disapproved of vitamin D testing and treatment, citing the lack of evidence on benefits and harms. One participant explained it this way: “There’s a lot of not very good evi-dence, and I’m not going to spend a lot of my time there.” Those participants who did conduct vitamin D testing and treatment among their patients followed conservative protocols, limiting the amount of vitamin D used in sup-plementation and frequently monitoring the levels of those patients taking higher doses. These participants also mentioned engaging patients in educational discussions on the benefits and risks of vitamin D supplementation.

Some participants expressed outright cynicism toward vitamin D testing and supplementation. Some of these participants felt strongly that the surge in attention toward vitamin D that had been expressed by their patients and in the media was directly related to the marketing strategies of vitamin and pharmaceutical companies. Others

mentioned frustration in the continual need to deal with the issue in a context that lacks consistent guidelines and evidence. Table 4 displays the breakdown of subthemes and exemplar quotes for Theme 4.

Discussion

From our small study, it appears that primary care clini-cians use an interesting set of strategies to deal with the clinical uncertainty surrounding vitamin D management. The first two themes we identified through the study data are not surprising for a group of primary care clinicians. These clinicians defaulted to listening to the wishes of the patient, and in the absence of contradictory evidence and in the setting of a favorable risk–benefit assumption, acceded to their wishes. Clinicians often felt frustrated about this patient demand, knowing that it came from sources they did not regard as authoritative, such as mass media or patient social circles. However, it is far from unprecedented to see patient demand drive physician practice (Hahn, Morley, Morrow, & Epling, 2009). The decision is often made to order testing because of time

Table 2. Theme 2: Reflexive Acceptance of Patient Demand.

Component Theme Subcategory Exemplar Quotation

Screening and Treatment are Benign

Patient Anxiety “I think it’s pretty benign.”“We do a lot of things for patients’ peace of mind. That’s the

reality.”Insurance Issues Reimbursement

Coding“I did some screening, and then I got nasty notes from the lab

saying that insurance wasn’t going to pay for it.”“At eight cents a pill, it’s a cheap way to do it, and that way you

don’t have to deal with the whole issue of insurance. Sometimes it pays for it, and sometimes it doesn’t.”

Patient Finances “If anyone was worried and they were uninsured, I would just tell them, ‘Take vitamin D.’”

“ . . . as far as how much is coming out of the patient’s pocket. And, that dictates whether you write a prescription or you make a recommendation for it.”

Table 3. Theme 3: Incorporation Into Patient Care as a Diagnostic Tool.

Component Theme Subcategory Exemplar Quotation

Assessment of Patient History

Screening by Risk Factors

“I screen based—I actually test based on patient history, so very individual based.”

“I don’t call it screening, I call it diagnosis. So if somebody’s got osteoporosis, or kidney stones, or chronic kidney failure—yeah, I check their vitamin D.”

Treatment by Symptom Complex

“This is in terms of the three mains things I look at really are energy, mood, muscle aches and pains. As to what they are at baseline, and then depending on what we do, how much change they have in their symptoms over time.”

“Yeah, it depends on the concomitant disease. It’s not just an absolute value of vitamin D alone.”

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

6 Qualitative Health Research

pressures in the office, persistence of the patient, and/or the quick estimation of potential harm. The quick risk–benefit assumption made by clinicians to justify ordering testing and treatment is often made based on personal experience or the experience of other clinicians, and not on a real estimation of risk.

The third theme of incorporation as a diagnostic tool is reminiscent of Everett Rogers’ theory of Diffusion of Innovations concerning compatibility (Rogers, 2003). Clinicians uncomfortable with the idea of a general screening for low vitamin D looked for justification in symptom complexes and other diseases or risk factors to alleviate this discomfort. They were, in effect, “reinvent-ing” the idea of testing to make it more compatible with an established, disease-focused model of care. We identi-fied a set of adaptations to uncertainty that ranged from healthy skepticism to outright cynicism within the last theme of doubt. Although several of the cynical attitudes expressed during the focus groups were apparently offered in a humorous vein, it is interesting to consider the impact of these latter attitudes leaking into doctor–patient interactions about this issue.

The actual clinical practice of testing or screening for low vitamin D and its subsequent replacement or sup-plementation varied to a surprising degree. Despite a generation or more of teaching that reinforced the poten-tial toxicity of fat-soluble vitamins such as vitamin D, the clinicians in the focus groups appeared to have somewhat easily dismissed this caution. Treatment

practices, even with high-dose vitamin D replacement, were widely disparate, and were often based on what the clinicians interpreted as the treatment practices con-ducted by their peers.

There are several limitations to the study outlined in this article. The subjects included in the focus groups were identified via convenience sampling from our prac-tice-based research network. We initially found it hard to recruit a mixed group of clinicians to travel to a session dedicated to the study, so we met with groups at confer-ences and in their own practices instead. In two instances, nonprimary care clinicians attended the groups: one med-ical student who was rotating in the visited office and one endocrinologist who was part of the multispecialty prac-tice. We noted and de-emphasized comments from these participants in the transcripts during analysis. We sam-pled only clinicians in the central New York region, and the physicians in these groups were all part of an exten-sive university teaching network; thus, their opinions might not generalize in any substantive way to other pri-mary care physicians. Additionally, there are questions that the study could not address, in part because they were (and are) evolving in real time. For example, a test-ing-and-treating regimen for vitamin D management might unwittingly serve a gatekeeping function, and work against universal supplementation. This issue is worthy of future exploration, along with continued research on the implementation of guidelines and recommendations as they develop.

Table 4. Theme 4: Doubt.

Component Theme Subcategory Exemplar Quotation

Skepticism Harms Unknown “When there isn’t evidence that’s compelling to do something, I think about, well, if we decide to do it could it cause any harms?”

“And you worry, you know, am I causing more harm than good, I guess?”

Conservative Approach

“I would have to say that I’m just waiting for someone to show me some clear evidence that this is why we do this and it is beneficial in these instances. And I haven’t seen that yet.”

“I also will check vitamin D levels when patients are taking really high doses of vitamin D—which by the way I did not recommend you do—just to make sure that they’re not taking an excessive amount.”

Cynicism Distrust of Profit-Making Entities

“So I don’t screen. I would screen—it’s a scam by the vitamin companies.”

“I just don’t know what benefit it’s having on my patients and if their insurance is covering it; someone is making money off all these tests I’m ordering.”

Lack of Consistency in Guidelines

“Yes! Yeah, I think we are out on a limb here. We are putting a huge effort into it, and we are not sure.”

“There’s really no good evidence.”“Well, I have not seen good guidelines for this, and I think we are all

making this up as we go.”

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

Epling et al. 7

During the course of conducting the focus groups, the Institute of Medicine (2011) published Dietary Reference Intakes for Calcium and Vitamin D, which recommends universal supplementation rather than testing and treating most people. This guideline was not mentioned in any of the four groups conducted after it was published. It appears that these guidelines have not yet reached a wide audience.

The findings detailed in this article reinforce a descrip-tion of knowledge management in primary care practice in the United Kingdom—the concept of “mindlines”:

. . . internalized, collectively reinforced and often tacit guidelines that are informed by clinicians’ training, by their own and each other’s experience, by their interactions with their role sets, by their reading, by the way they have learnt to handle the conflicting demands, by their understanding of local circumstances and systems and by a host of other sources. (Gabbay & le May, 2011, p. 44)

The overall impression of the formation of emerging practice concerning vitamin D is that it was often initiated by patient demand, but was then constructed and rein-forced by incidental reading; brief, purposeful research; influence by physician champions; informal conversa-tions with colleagues; results of consultations by special-ists; and more patient demand. There was only a rare example of physicians actively attempting to “break out” of this swirl of constructed knowledge and find an answer for themselves based on evidence or high-quality guide-lines. Instead, they largely relied on the social transmis-sion and construction of this new knowledge, through interactions with patients, colleagues, and the media.

These findings also mirror the results of Bennett et al.’s (2014) study of uncertainty management, wherein many physicians adopted a mixture of passive informa-tion-seeking strategies (e.g., educational conferences or unsolicited literature) and active information-seeking strategies (e.g., discussions with colleagues) to manage the uncertainty surrounding vitamin D, with few physi-cians conducting interactive information seeking, such as conducting directed, evidence-based literature reviews.

Conclusion

The clinical practice of vitamin D testing and treatment in primary care practice appears to vary widely, is driven by media-reinforced patient demand, and is based on a framework of constructed knowledge from a variety of sources, mostly social connections in primary care prac-tice. We have documented significant variation in prac-tice concerning vitamin D, the impacts of which remain unknown and could be potentially harmful. This variation is deeply set within “mindlines.” To promote the use of

the best knowledge about vitamin D screening and man-agement, clear, authoritative guidelines are only a first step. Promoting active and intentional communities of practice through which primary care clinicians can inter-pret, refine, and contextualize this guideline information might improve the dissemination of this knowledge into clinical practice (Gabbay & le May, 2011).

Acknowledgments

We thank Kathleen Barzee for assistance with background doc-ument preparation and Amber Smith for editorial review of the final manuscript for this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: HRSA grant #D54HP23297 (Christopher P. Morley, PI/PD) supported this work.

References

Avenell, A., Gillespie, W. J., Gillespie, L. D., & O’Connell, D. L. (2009). Vitamin D and vitamin D analogues for prevent-ing fractures associated with involutional and post-meno-pausal osteoporosis. Cochrane Database of Systematic Reviews (Online), 2, CD000227.

Bennett, K., Frisby, B. N., Young, L. E., & Murray, D. (2014). Vitamin D: An examination of physician and patient man-agement of health and uncertainty. Qualitative Health Research, 24, 375–386. doi:10.1177/1049732314523681

Binkley, N., & Wiebe, D. (2013). Clinical controversies in vita-min D: 25(OH)D measurement, target concentration, and supplementation. Journal of Clinical Densitometry, 16(4), 402–408. doi:10.1016/j.jocd.2013.08.006

Cao, Y., Winzenberg, T., Nguo, K., Lin, J., Jones, G., & Ding, C. (2013). Association between serum levels of 25-hydroxyvitamin D and osteoarthritis: A systematic review. Rheumatology (Oxford, England), 52(7), 1323–1334. doi:10.1093/rheumatology/ket132

Cohen, D. J., & Crabtree, B. F. (2008). Evaluative criteria for qualitative research in health care: Controversies and rec-ommendations. Annals of Family Medicine, 6(4), 331–339. doi:10.1370/afm.818

Diaz, V. A., Mainous, A. G., Carek, P. J., Wessell, A. M., & Everett, C. J. (2009). The association of Vitamin D defi-ciency and insufficiency with diabetic nephropathy: Implications for health disparities. Journal of the American Board of Family Medicine, 22(5), 521–527. doi:10.3122/jabfm.2009.05.080231

Gabbay, J., & le May, A. (2011). Practice-based evidence for healthcare: Clinical mindlines. New York: Routledge.

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from

8 Qualitative Health Research

Hahn, W., Morley, C. P., Morrow, C., & Epling, J. W. (2009). The effect of media attention on concern for and medi-cal management of methicillin-resistant Staphylococcus aureus: A multimethod study. Journal of Public Health Management and Practice, 15(2), 150–159. doi:10.1097/01.PHH.0000346013.74522.f8

Holick, M. F., Binkley, N. C., Bischoff-Ferrari, H. A., Gordon, C. M., Hanley, D. A., & Heaney, R. P., . . . Endocrine Society. (2011). Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology and Metabolism, 96(7), 1911–1930. doi:10.1210/jc.2011-0385

Institute of Medicine. (2011). Dietary reference intakes for cal-cium and vitamin D. Washington, DC: National Academies Press. Retrieved from www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx

Kulie, T., Groff, A., Redmer, J., Hounshell, J., & Schrager, S. (2009). Vitamin D: An evidence-based review. Journal of the American Board of Family Medicine, 22 (6 ), 698–706. doi:10.3122/jabfm.2009.06.090037

Motiwala, S. R., & Wang, T. J. (2011). Vitamin D and car-diovascular disease. Current Opinion in Nephrology and Hypertension, 20(4), 345–353.

Pilz, S., Kienreich, K., Tomaschitz, A., Ritz, E., Lerchbaum, E., Obermayer-Pietsch, B., . . . Dekker, J. M. (2013). Vitamin D and cancer mortality: Systematic review of prospective epidemiological studies. Anti-Cancer Agents in Medicinal Chemistry, 13(1), 107–117. Retrieved from www.ncbi.nlm.nih.gov/pubmed/23094928

Pope, C., Ziebland, S., & Mays, N. (2000). Qualitative research in health care: Analysing qualitative data. BMJ, 320(7227), 114–116. doi:10.1136/bmj.320.7227.114

Rogers, E. M. (2003). Diffusion of Innovations (5th ed.). New York: Simon & Schuster.

Sackett, D. L., Rosenberg, W. M., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medi-cine: What it is and what it isn’t. BMJ, 312(7023), 71–72. doi:10.1136/bmj.312.7023.71

Scientific Software Development GmbH. (2014). ATLAS.ti. (Version 7) [Computer Software]. Corvallis, OR: Author.

Shahangian, S., Alspach, T. D., Astles, J. R., Yesupriya, A., & Dettwyler, W. K. (2014). Trends in laboratory test volumes for Medicare Part B reimbursements, 2000–2010. Archives

of Pathology & Laboratory Medicine, 138(2), 189–203. doi:10.5858/arpa.2013-0149-OA

Slawson, D. C., & Shaughnessy, A. F. (1999). Teaching infor-mation mastery: Creating informed consumers of medical information. Journal of the American Board of Family Practice, 12(6), 444–449. doi:10.3122/jabfm.12.6.444

Stockton, K. A., Mengersen, K., Paratz, J. D., Kandiah, D., & Bennell, K. L. (2011). Effect of vitamin D supplementation on muscle strength: A systematic review and meta-analysis. Osteoporosis International, 22(3), 859–871. doi:10.1007/s00198-010-1407-y

Wang, L., Song, Y., Manson, J. E., Pilz, S., März, W., Michaëlsson, K., . . . Sesso, H. D. (2012). Circulating 25-hydroxy-vitamin D and risk of cardiovascular dis-ease: A meta-analysis of prospective studies. Circulation. Cardiovascular Quality and Outcomes, 5(6), 819–829. doi:10.1161/CIRCOUTCOMES.112.967604

Yin, L., Grandi, N., Raum, E., Haug, U., Arndt, V., & Brenner, H. (2009). Meta-analysis: Longitudinal studies of serum vitamin D and colorectal cancer risk. Alimentary Pharmacology & Therapeutics, 30(2), 113–125. doi:10.1111/j.1365-2036.2009.04022.x

Author Biographies

John W. Epling, MD, MSEd, is an associate professor of fam-ily medicine, an associate professor of public health and preven-tive medicine, and chair of the Department of Family Medicine at SUNY Upstate Medical University in Syracuse, New York, USA.

Emily M. Mader, MPH, MPP, is a clinical research associate and research instructor in the Department of Family Medicine at SUNY Upstate Medical University in Syracuse, New York, USA.

Carrie A. Roseamelia, MA, is a staff associate and research instructor in the Department of Family Medicine at SUNY Upstate Medical University, in Syracuse, New York, USA.

Christopher P. Morley, PhD, MA, is an associate professor of family medicine, an associate professor of psychiatry and behavioral sciences, and an associate professor of public health and preventive medicine at SUNY Upstate Medical University in Syracuse, New York, USA.

at University at Buffalo Libraries on October 29, 2014qhr.sagepub.comDownloaded from