Evaluation of Vitamin D Screening in a Pediatric Severe Asthma Clinic
Purpose: The purpose of this quality improvement project was to evaluate vitamin D deficiency screening and
treatment practices in an outpatient pediatric asthma and allergy clinic setting at a large, urban pediatric medical
center. The population of interest included those children and adolescents with severe persistent asthma.
Background and Significance: Vitamin D plays an important role in immunity, especially in the asthma population;
thus, the screening practices for this deficiency is supported by evidence, but have not been made an official
recommendation.
The primary outcome for this project was to determine if Vitamin D screening for deficiency occurred in the
pediatric and adolescent severe-persistent asthma population enrolled in the severe asthma clinic.
The secondary outcomes measured included (1) the number of patients with severe persistent asthma whose
vitamin D status was evaluated, (2) the number of children identified as vitamin D deficient (<20ng/ml 25(OH)D
concentration) (3) the number of children who were provided vitamin D supplementation, and (4) evaluating for a
correlation between vitamin D supplementation (treatment) and ACT scores at each follow-up visit up to one-year
post-screening
Design: A retrospective chart review of medical records for 26 patients treated in a severe asthma clinic was
performed. Sample: Following IRB approval from both institutions involved, the convenience sample included
patients who were enrolled in the severe asthma clinic from January 2014 to December 2015. Vitamin D levels,
Asthma Control (ACT) or Childhood Asthma Control Tests (c-ACT) scores, and supplementation (if any) data were
evaluated. Demographic data was recorded. Asthma Control Test scores at the time the vitamin D test was ordered
and at each follow-up visit after the screening for up to one-year was recorded in addition to calcitrol (vitamin D)
values, and the occurrence of vitamin D supplementation. Instruments: Asthma Control Test (ACT) and c-ACT
scores indicating well controlled asthma are >20 (Schatz et al., 2006). Vitamin D deficiency was defined as
<20ng/ml 25(OH)D concentration (Holick & Chen, 2008; Gordon, 2014). Analysis: Confidence intervals for
patients who were screened for co-morbidity screenings, average calcitrol levels, and ACT scores for those who
were tested for vitamin D deficiency were calculated. Means were calculated for the average calcitrol levels, ACT
scores, and demographic data. An independent Sample t-test group statistics for calcitrol levels and ACT scores at
time of testing were performed. A paired Sample t-test group statistics for ACT scores pre-and post-supplementation
were also performed.
Results Eight children had serum diagnostics drawn. Of those, 62% (n=5) received vitamin D testing. Two of five
(40%) were deficient. Both children (100%) were supplemented, however. The vitamin D deficient group’s mean
ACT scores at time of vitamin D testing was 20 (sd=.00) and was unexpectedly higher than the vitamin D nondeficient group (m=16.67, sd=4.01). The difference between the two means was not statistically significant
(t=1.107, df= 3). For patients supplemented with Vitamin D, follow up ACT scores were >20, indicating wellcontrolled asthma
Clinical Implications This study provided some evidence of vitamin D screening having occurred.
Recommendation are to continue screening process for vitamin D levels for all patients enrolled in the severe asthma
clinic who are undergoing blood draws for co-morbidities. Consideration to expand the screening to all patients
enrolled in the severe asthma clinic is recommended. Future study recommendation is to evaluate vitamin D
screening and vitamin D supplementation compared with ACT scores in larger sample sizes as this may provide
more information regarding these practices. Due to this evaluation study, clinic providers reported a change in
practice to reduce the number of missed screening opportunities. Further study may be indicated to evaluate these
practices changes.
Abigail Schamel Kleinschmidt, DNP, RN, CPNP-PC, AACNS-P
Pediatric Nurse Practitioner, St. Louis Children’s Hospital, St. Louis, Missouri
Study IRB approval by:
NAPNAP Research Agency Priority:
University of Missouri-Columbia; Washington University School of
Medicine in St. Louis
Quality of Care and/or Self -Management of Acute & Chronic Illness
Evaluation of Vitamin D Screening in a Pediatric Severe Asthma Clinic
Abigail Schamel Kleinschmidt, DNP, APRN, CPNP-PC, ACCNS-P
University of Missouri-Columbia
Sinclair School of Nursing
Introduction
Vitamin D plays an important role in
immune health and a supportive role in
treating steroid resistant asthma.
Research shows a positive correlation
between Vitamin D levels,
supplementation, and/or asthma outcome
measurements such as exacerbations
(Brehm et al., 2010; Brehm et al., 2012;
Freishtat et al., 2010; Majak et al., 2011;
Wu et al., 2012).
•  Screening practices for this deficiency
is supported by evidence, but has not
been made a recommendation.
Setting & Population:
•  Outpatient severe pediatric asthma and
allergy clinic in a large, urban pediatric
medical center.
•  Children and adolescents with severe
persistent asthma seen in the severe
asthma clinic and who were screened
for other co-morbidities with serum
diagnostics.
The primary outcome:
• to determine if Vitamin D
deficiency screening
occurred.
The secondary outcomes:
1.  Number of patients with severe persistent
asthma whose vitamin D status was
evaluated
2.  Number of children identified as VDD as
defined as less than 20ng/ml 25(OH)D
concentration
3.  Number of children who were provided
vitamin D supplementation
4.  Evaluating for a correlation between
vitamin D supplementation (treatment) and
ACT scores at each follow-up visit up to
one-year post-screening
Methods
•
•
•
•
Conclusion
Retrospective descriptive design
26 patients in the severe asthma clinic
January 1, 2014 to December 31, 2014
Institutional Review Boards approval:
University of Missouri-Columbia and
Washington University-St. Louis
School of Medicine.
Data reviewed:
•  ACT scores
•  Supplementation occurrence (if any)
•  Demographic data (age, gender,
race).
•  ACT scores at the time of calcitrol
level & at follow-up visits for up to
one-year
•  Calcitrol levels
Future Direction
Anticipated results:
•  Not all of patients enrolled in the severe
asthma clinic would receive co-morbidity
serum diagnostics.
•  All of the patients who screened for
other co-morbidities would be tested for
vitamin D deficiency.
Continued screening
process for vitamin D
levels for all patients
enrolled in the severe
asthma clinic who are
undergoing blood draws
for co-morbidities.
Actual results:
•  5/8 (62%) patients whose blood was drawn
for co-morbidity reasons also received
vitamin D screening
•  Missed opportunities for vitamin D
deficiency screening.
Develop standard for
vitamin D level retesting follow-up
timeline
•  62.5% (5
of 8)
screened
for comorbidities
were
screened
for VDD
•  19.2% (5
of 26) of
severe
asthma
clinic was
screened
Clinic providers
reported a change in
practice to reduce the
number of missed
screening opportunities
after sharing results of
this quality
improvement project
•  Additional study to evaluate
changes in practice
reported by providers
Results
Primary
Outcome:
Consider expanding to
all severe persistent
asthma patients
Unanticipated additional findings:
Secondary
Outcome:
•  40%
patients
identified
as VDD
Secondary
Outcome:
Secondary
Outcome:
•  100%
were
supplem
ented
with
vitamin
D when
found
VDD
(<20ng/
ml)
•  VDD
displayed
higher initial
ACT than
NVDD
•  VDD ACT
score after
supplement
ation
increased
.
slightly
•  Both not
statistically
significant
•  13% - 49% of the time (95% CI [0.13,
0.49]) patients with severe asthma were
obtaining serum diagnostics for co-morbid
conditions.
•  Screening for Vitamin D in this
population would be convenient; nearly
half of the children enrolled in the clinic
would not experience additional needle
sticks for Vitamin D screening.
•  The average calcitrol level for those tested
(n=5) was 20.4 ng/mL (sd=8.20) with a
range from 10 ng/ml to 29 ng/ml
•  Both children (n=2) who were found to be
vitamin D deficient were prescribed
Vitamin D supplementation.
Due to a small sample size calculations at
the effect level of 0.05 and a power of 95%
could not be achieved.
The VDD group’s mean ACT scores at time
of vitamin D testing was 20 (sd=.00) and was
unexpectedly higher than the vitamin D nondeficient group (m=16.67, sd=4.01). The
difference between the two means was not
statistically significant (t=1.107, df= 3).
•  Providers were following up and
attempting to treat children when
indicated.
Develop paper or
computerized provider
order entry template for
reminder system
Standardized dosage of
D3 for treatment of
vitamin D deficiency
A collaborative team
approach between asthma
specialists and primary
care providers to prevent
duplicate co-morbidity
screenings
Acknowledgements
University of Missouri- Columbia
Sinclair School of Nursing, DNP Program
Committee Members:
• Laura Kuensting, DNP, APRN, PCNS-BC,
CPNP, CPEN
• Lila Kertz, MSN, APRN, CPNP, AE-C
• Debra Gayer, PhD, RN, CPNP – PC