From downturns to downsizing. From unemployed to underemployed. Supply and demand. Outsouring. Entitlements. Making ends meet. Do more with less. While many healthcare workers count their pennies and stretch their dollars, economists readily pad their dictionaries with these terms. They can add one more, spawned from these hard times: Presenteeism.
With healthcare facilities operating at lower staffing levels, those on the job working long hours often find themselves present -- but not fully functional for a variety of health-related reasons.
Gregory A. Plotnikoff, MD, MTS, FACP, and a team of like-minded colleagues, set about on a mission to prove that proper use of Vitamin D -- as a step before the leap of primary care physicians to recommend drugs to treat conditions like hypertension and coronary disease -- could prove less costly and just as effective, without the side effects of prescription drugs.
"Even today, Vitamin D testing is too often an afterthought," said Plotnikoff, adding that studies exist in the medical literature from the VA and other systems that document the cost savings from ensuring a normal vitamin D level. "Vitamin D represents the single most cost-effective intervention we have in medicine. This means that testing is the most cost-effective means of avoiding over-medicating, over-hospitalizing and under-diagnosing patients."
Dollars and Sense
Even in cases where patients have progressed to the point of needing prescription medication, Plotnikoff is adamant that Vitamin D does not become null and void. He added that vitamin D naysayers simply haven't done their research, as the vitamin can be effective as part of treatments for metastatic cancer, pain (low back, chest, sickle cell pain crisis, fibromyalgia), fatigue, depressed mood, idiopathic dilated cardiomyopathy, neuromuscular weakness and/or balance/falls.
"Many drugs function better with normal vitamin D levels," he said. "This includes multiple medications used in oncology as well as many immune treatments such as interferon for hepatitis C. Many drugs can be prescribed inappropriately if Vitamin D deficiency has not been considered and ruled out."
Plotnikoff calculated, based on employees' anonymous self-reports of presenteeism to their employer, a savings of up to 2.3 million dollars per year for the higher serum levels at one healthcare system, Allina Healthcare in Minnesota.
The study -- funded in part by DiaSorin -- commenced in 2010 and 2011,when Vitamin D levels of 13, 400 Allina workers were tested and only 4% were found to be at a good level.
The study found 60% were low, 30% very low and 6% profoundly low. This is despite significant press coverage of Vitamin D deficiency issues. When serum levels are corrected, productivity differences translated into potential productivity savings of 0.191%, 0.553%, and 0.625%, respectively, of total payroll costs.
"Through our study of more than 10,000 employees of the Allina Health System, we found if every employee had a serum level of 40 ng/ml or greater, the system would have saved $2.3 million in presenteeism costs," Plotnikoff said. "We are currently looking at Vitamin D levels and total cost of care. Initial reviews have suggested cost savings many fold higher than this."
The Role of Labs
Plotnikoff said that daily multi-vitamins fail to meet the daily dosage required by most Americans, healthy or not, and that laboratory professionals must play a key role in dispelling the notion that all Vitamin D doses are created equally.
"Vitamin D dosing is an extremely poor predictor of Vitamin D sufficiency," he said. "Vitamin D testing is the only way to know anyone's Vitamin D level. Vitamin D testing is under-utilized. There is really no logical reason why we should be doing significantly more B12 or TSH testing than Vitamin D testing."
"The Food and Nutrition Board of the National Academy of Sciences has asserted that the best evidence supports that a 25(OH) Vitamin D level greater than or equal to 20 ng/ml is the definition of Vitamin D sufficiency. This has been heavily criticized from multiple authoritative bodies. The most authoritative, the Endocrine Society, asserts that 30 ng/ml is the minimum definition with ideal likely to be 40-60 ng/ml."
Plotnikoff noted that "no one has argued for a level less than 20 ng/ml. However, even at this minimal definition, huge percentages of the world's population fails to meet this goal."
He explained that this includes people in not just northern hemisphere countries -- i.e. almost all of Europe and North America north of New York, Chicago, San Francisco -- but people in "sunny countries" such as the Middle East/Gulf Arabic states.
Plotnikoff pointed to physiologic measures of normalcy -- for example, the correlation of Vitamin D levels with PTH levels, where there is an inflection of the Vitamin D/PTH curve at 20 ng/ml with PTH minimized at 40 ng/ml. He identified other studies, where bone mineral density is found at levels greater than 20 ng/ml  and, moreover, a dozen studies with over 40,000 participants have demonstrated that 20 ng/ml is not enough to prevent either fractures or falls but higher levels do. 
The WHO recommends 500 mg a day of calcium (about a cup of yogurt) from all sources for Vitamin D sufficient women, he explained.
"Far too many people are on far too much calcium," said Plotnikoff, adding that the recommendations for high dose calcium supplementation (>1000 mg a day) appears to be based on Vitamin D deficient women. "Simply raising a Vitamin D level from 20 to 32 ng/ml improves calcium absorption by 65 percent. Where does that calcium go? Not into the bones."
Getting the Word Out
With such compelling and continuing evidence about the importance of Vitamin D testing, assay manufacturers are continuing to refine their tests.
Diazyme Laboratories, for example, announced in March that the FDA has granted 510(K) clearance to market its Vitamin D assay for clinical chemistry analyzers. This new test, utilizing Diazyme's FemtoQuant technology (a sensitive homogenous enzyme-immunoassay platform), provides the first fully automated Vitamin D test for use on general clinical chemistry analyzers.
But Plonikoff, from his vantage point, still sees a long journey ahead when it comes to changing the mindset of the medical community, ranging from laboratory professionals to primary care physicians to specialists.
"Please help get the word out," he implored. "Vitamin D is not a vitamin. It is a hormone as important as any other hormone in your body. There are Vitamin D receptors on nearly every tissue, including brain cells -- both cognitive and emotional -- every immune cell, every bone marrow cell and every skeletal muscle cell. A multivitamin or a prenatal vitamin does not ensure vitamin D sufficiency for more than 50% of the population. And, too often, we cannot make enough Vitamin D due to latitude, winter, sun block, use of some prescription medications or herbal medicines, skin color and/or working long hours indoors.
"Vitamin D deficiency is linked to a huge number of adverse health states. Failure to measure Vitamin D levels undermines good medical care and likely confounds a large percentage of clinical trials."
1. Am J Med. 2004; 116:634-9; J Bone Miner Res. 2009; 24(5): 935-42.
2. BMJ 2009; 339:b3692; Arch Int Med. 2009;169:551-561.