1. B9? Not so much.
Ian Lizardo

2. 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.

3. Labs
Na Hgb K Hct Cr MCV Glucose Albumin 3.7

4. Gut reaction:

5. More results!
Folate Vitamin B12 662

6. 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.

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

8. Back to her labs...
Na Hgb K Hct Cr MCV Glucose Albumin 3.7
Folate Vitamin B TSH FT

9. Back to her labs... Did we need this?
Na Hgb K Hct Cr MCV Glucose Albumin 3.7
Folate Vitamin B TSH FT
Did we need this?

10. Yes, it’s macrocytic anemia!

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

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

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

14. 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

15. 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 February;8(2):91-95

17. 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

18. 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

19. As opposed to...

21. 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.

22. 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