B9? Not so much. Ian Lizardo

48 year old female... presents to the emergency room with gradually worsening generalized fatigue for the past three weeks. Heart rate 97, otherwise vitals unremarkable. She lives in Southern California, eats three square meals a day with a multivitamin, and has no other known medical problems.

Labs Na 137 Hgb 10.5 K 4.2 Hct 31.4 Cr 0.6 MCV 100.5 Glucose 96 Albumin 3.7

Gut reaction:

More results! Folate 10.3 Vitamin B12 662

Further developments She later tells you she has had constipation, cold sensitivity, gained 10 lbs over the last month, and that family members have told her she’s been more irritable recently. Exam reveals brittle nails and thinned hair and skin.

Further developments TSH 9.34 FT4 0.3 She is started on Synthroid and sent home.

Back to her labs... Na 137 Hgb 10.5 K 4.2 Hct 31.4 Cr 0.4 MCV 100.5 Glucose 96 Albumin 3.7 Folate 10.3 Vitamin B12 662 TSH 9.34 FT4 0.3

Back to her labs... Did we need this? Na 137 Hgb 10.5 K 4.2 Hct 31.4 Cr 0.4 MCV 100.5 Glucose 96 Albumin 3.7 Folate 10.3 Vitamin B12 662 TSH 9.34 FT4 0.3 Did we need this?

Yes, it’s macrocytic anemia!

But... * Folate testing may be omitted if diet and gastrointestinal anatomy and function are normal.

Still, the test doesn’t cost that much... right?

Still, the test doesn’t cost that much... right? ...well, this is a cost-conscious project presentation.

A few facts on folate: U.S. and Canada mandated fortification of processed grains with folic acid in 1998 Increased average daily folic acid intake by 100 mcg/day Recommended dietary allowance: 200 mcg/day Folic acid deficiency has become vanishingly rare UpToDate: <2 ng/mL is low; >4 ng/mL is normal

Utility, charge, cost of serum folate testing 2013 retrospective study in Boston over one calendar year 1944 ED patients and inpatients 2093 serum folate levels reviewed Most common indications: anemia w/ or w/o macrocytosis, delirium, malnutrition, peripheral neuropathy How many patients were considered folate deficient? (defined by this study as < 3 ng/mL) Theisen-Toupal et al. Utility, charge, and cost of inpatient and emergency department serum folate testing, J. Hos. Med. 2013 February;8(2):91-95

Utility, charge, cost of serum folate testing Cost for the 2,000+ tests: $316,043 Amount charged per deficient result: $158,022 Cost to the hospital: $4,186 Cost per deficient result: $2,093

How much does it cost our patients? For self-pay patients at UCI: Patients paying to have test done: $16.34 Patients being billed by the hospital: $49.02

As opposed to...

Choosing Wisely: American Society for Clinical Pathology Do not order red blood cell folate levels at all. In adults, consider folate supplementation instead of serum folate testing in patients with macrocytic anemia. Since 1998, when the U.S. and Canada mandated that foods with processed grains be fortified with folic acid, there has been a significant decline in the incidence of folate deficiency. For the rare patient suspected of having a folate deficiency, simply treating with folic acid is a more cost-effective approach than blood testing. While red blood cell folate levels have been used in the past as a surrogate for tissue folate levels or a marker for folate status over the lifetime of red blood cells, the result of this testing does not, in general, add to the clinical diagnosis or therapeutic plan.

In short: In patients living in countries with folic acid fortification (e.g. U.S. and Canada), dietary folate deficiency is exceedingly rare Ordering folate tests routinely is of very little value without a convincing medical history In patients where folate deficiency is possible, consider folic acid supplementation without serum folate testing e.g. pregnant women not taking MVs or grains, malnourished alcoholics, patients with malabsorption syndromes