Serum folate testing is significantly overused given the “exceedingly low” rates of detected serum folate deficiencies, according to a research letter published Aug. 11 in JAMA Internal Medicine. While serum folate testing is proving financially beneficial for laboratories and medical centers, it should be significantly cut or eliminated in the name of providing high-value care, the authors suggest. The researchers retrospectively reviewed all outpatient serum folate tests performed at Beth Israel Deaconess Medical Center (Boston) from 2003 through 2013. The researchers found that over the study period, 84,187 serum folate tests were performed in 77,627 individuals. Levels were classified deficient (less than 3 ng/mL; 0.056 percent), low-normal (3-3.9 ng/mL; 0.197 percent), normal (4-19.9 ng/mL; 68.195 percent), and high (more than 19.9 ng/mL; 31.552 percent). Ordering habits have not changed over the last decade relative to routinely ordered tests like creatinine, the authors found, despite the significant reduction in folate deficiency since folic acid fortification of processed grains began in 1998. Indicators are that folate testing is widespread nationally. The 2014 College of American Pathologists Ligand (General) K-A Proficiency Testing Survey found that 2,137 laboratories report results of serum folate and 225 laboratories report red blood cell folate. This total of […]
Serum folate testing is significantly overused given the “exceedingly low” rates of detected serum folate deficiencies, according to a research letter published Aug. 11 in JAMA Internal Medicine. While serum folate testing is proving financially beneficial for laboratories and medical centers, it should be significantly cut or eliminated in the name of providing high-value care, the authors suggest.
The researchers retrospectively reviewed all outpatient serum folate tests performed at Beth Israel Deaconess Medical Center (Boston) from 2003 through 2013. The researchers found that over the study period, 84,187 serum folate tests were performed in 77,627 individuals. Levels were classified deficient (less than 3 ng/mL; 0.056 percent), low-normal (3-3.9 ng/mL; 0.197 percent), normal (4-19.9 ng/mL; 68.195 percent), and high (more than 19.9 ng/mL; 31.552 percent). Ordering habits have not changed over the last decade relative to routinely ordered tests like creatinine, the authors found, despite the significant reduction in folate deficiency since folic acid fortification of processed grains began in 1998.
Indicators are that folate testing is widespread nationally. The 2014 College of American Pathologists Ligand (General) K-A Proficiency Testing Survey found that 2,137 laboratories report results of serum folate and 225 laboratories report red blood cell folate. This total of 2,362 is essentially identical to the 2,340 laboratories that reported vitamin B12 test results from this same survey.
“Eliminating folate testing and other antiquated clinical laboratory tests is the responsibility of the laboratory itself and requires cooperation of the clinical staff,” writes Alan H. B. Wu, Ph.D., in an accompanying editorial. His own clinical chemistry laboratory at San Francisco General Hospital eliminated in-house red blood cell and folate testing, which has greatly reduced the volume of test requests. For those patients in whom folate deficiency is strongly suspected, samples are sent to an outside reference laboratory for testing.
Eliminating folate testing may actually pose a financial challenge to many institutions. In the Beth Israel Deaconess Medical Center study, the authors examined 2014 institutional costs and charges (less than $2 per test and $128 per test, respectively), as well as a reimbursement assessment (based on the Medicare fee schedule of $20.02 per test). Costs totaled $168,374 ($3,582.43 per deficient result), while charges totaled $10,775,936 ($229,275.23 per deficient result). Reimbursements totaled $1,685,423.74, yielding a net surplus of $137,913 per year for the medical center, which the authors call “an interesting financial dilemma.”
“Every physician and medical center should aim to provide high-value care,” conclude the authors, led by Jesse Theisen-Toupal, M.D. “In the case of serum folate, this would mean a significant reduction, or perhaps elimination, of testing, which in fee-for-service payment models would result in a significant loss in revenue to the medical center.”
