Improving Vitamin B12 Screening in Diabetes Patients

Health care delivery must change to meet the increasing demands for conservative stewardship in spending.

The Agency for Healthcare Research and Quality, the National Committee for Quality Assurance, and the Institute for Health Technology Transformation recommend population health management to reduce costs and improve outcomes.

Population health management prevents costly medical events by providing preventive services, monitoring, and other proactive measures. For example, the incorporation of tobacco cessation screening into routine physician office visits increased cessation by 40%. Previous indirect interventions include the use of electronic patient portals and the US Postal Service.

Monitoring vitamin B12 intake in diabetes patients receiving metformin is an opportunity to prevent peripheral neuropathy and megaloblastic anemia. No previously published studies focused on the impact of population health management on increasing the rate of recommended annual vitamin B12 screening.

Now, an article published ahead-of-print in Annals of Pharmacotherapy posits that face-to-face population health management increases vitamin B12 screening more effectively than electronic patient portal-based interventions. However, it’s more time consuming.

The study enrolled 489 patients receiving metformin for at least 12 months without vitamin B12 screening. The patients were already enrolled in an academic medical center’s electronic patient portal through their affiliated practitioners.

The researchers randomized providers to receive reminders to discuss screening with certain patients or have their patients directly receive reminders to ask for the screening. Pharmacists created either a physician-targeted intervention or a message for patients.

Office-based interventions were 4 times more effective in prompting vitamin B12 screening than patient portal reminders.

A previous study found that up to half of all patient portal messages are left unread. However, coordinating with physicians to identify targeted patients took 10 times longer to complete than the electronic message. The additional time was related to the need for the pharmacist to scan appointment schedules—an activity that requires dedicated staff members and staffing time.

The patient portal can also reach out to patients lost to follow-up (eg, those without scanning scheduled appointments).

Less than 1% of study patients had low vitamin B12 levels, and clinicians didn’t identify any negative sequelae at the time.

A hybrid approach bringing together the quick (but less effective) patient portal interventions and the more time-intensive and effective office-based interventions is ideal. The study authors recommended future studies to explore other electronic health record-based interventions and identify the causes of differing success rates between interventions.