Folate testing in hospital inpatients

Folate Deficiency in an Urban Safety Net Population

PURPOSE

Since mandatory fortification of grain products with folic acid in the United States in 1998, folate deficiency has become rare. Some have suggested that serum folate levels should be tested rarely in countries with mandatory folic acid fortification, given low rates of deficiency, high cost per deficiency diagnosis, and low rates of supplementation for those diagnosed as deficient. Given persistent racial, ethnic, and socioeconomic disparities in folate deficiency, these suggestions may not apply to all populations. We examine the rate at which serum testing detected folate deficiency in an urban safety net hospital and the characteristics of folate-deficient patients.

METHODS

We reviewed the charts of all inpatients and emergency department patients with low serum folate results at a safety net hospital in Boston in 2018. We collected data concerning demographics, social determinants of health, clinical factors, and whether folate supplementation was prescribed. Finally, we performed a cost analysis.

RESULTS

Of 1368 patients tested, 76 (5.5%) met criteria for folate deficiency. Overall, 86.8% of these patients were anemic, and 17.1% had macrocytic anemia; 42% were diagnosed with malnutrition. Common social determinants in folate-deficient patients included birth outside of the United States, homelessness, and alcohol use disorder. Of folate-deficient patients, 88% were newly prescribed folic acid supplementation at discharge. The estimated charge per deficient test was $1278.

CONCLUSION

Compared with a nearby institution, serum folate testing at our safety net hospital detected deficiency at a higher rate, incurred a lower charge per deficient test, and was more likely to impact management.

Inpatient folate testing at an academic cancer center: single-year experience

PURPOSE

The value of testing for folate deficiency has been scrutinized recently given low prevalence of deficiency with widespread dietary fortification. Numerous studies have shown folate testing to be low yield overall. However, the value of such testing in the inpatient cancer population has not been defined.

METHODS

We queried all folate tests performed during 2017 at our center on admitted cancer patients. We used diagnosis codes and manual chart review to assess risk factors for folate deficiency. Descriptive statistics were used to summarize characteristics of patients undergoing folate testing, the frequency of vitamin B12 co-testing, and repeat folate testing. Fisher's exact test was used to compare the proportion of deficient vs. not deficient tests based on the presence of risk factors. A Cox proportional hazards model was fit to examine the association between folate deficiency and survival.

RESULTS

In total, 937 patients had 1065 tests performed during 2017. Among all tests, 7.0% indicated folate deficiency. In patients who underwent two folate tests in a single hospitalization, 89% were deficient neither instance. Risk factors for folate deficiency were equally common in instances with deficient compared with replete testing (25.3 vs. 20.4%, P = 0.334). Folate deficiency was associated with higher risk for death (HR 1.49, 95% CI 1.10-2.03, P = 0.01).

CONCLUSION

Folate deficiency was present in 7% of hospitalized cancer patients and associated with shorter overall survival. Repeat testing in the same patient over time was low yield. Traditional risk factors for folate deficiency do not appear to apply in this patient population.

Preoperative anemia-screening clinics

Preoperative anemia is associated with increased postoperative morbidity and mortality and with increased risk of perioperative transfusion. It is an important and modifiable risk factor for surgical patients. For high-blood-loss surgery, preoperative anemia is defined as hemoglobin <13 g/dL for both male and female patients. Preoperative anemia is common, ranging from 25% to 40% in large observational studies. The most common treatable cause of preoperative anemia is iron-deficiency anemia; the initial laboratory tests should focus on making this diagnosis. Management of iron-deficiency anemia includes iron supplementation with IV iron therapy when oral iron is ineffective or not tolerated, there is severe anemia, and there is insufficient time to surgery (<4 weeks). In other situations, erythropoiesis-stimulating agents may be considered, particularly for those patients with multiple alloantibodies or religious objections to transfusion. To facilitate the diagnosis and management of preoperative anemia, establishment of preoperative anemia-screening clinics is essential. The goals of management of preoperative anemia are to treat anemia, reduce the need for transfusion, and improve patient outcomes.

Reducing red blood cell folate testing: a case study in utilisation management

Mandatory enrichment of wheat flour in Canada with folic acid since 1998 has caused folate deficiency to be rare. There were 3019 red blood cell (RBC) folate tests performed during an 18-month period at London Health Sciences Centre (LHSC)/St. Joseph's Healthcare London (SJHC) without any folate deficiency detected. We implemented a quality improvement initiative to reduce RBC folate testing at LHSC/SJHC. We began with a retrospective review of RBC folate tests performed during the previous 18 months. We identified physicians who had ordered more than five tests during this period and sent them an educational email to inform them of our intentions and solicit their input. We then discontinued RBC folate testing in-house and a pop-up window was introduced to the computerised physician order entry system stating that biochemist approval would be needed before samples would be sent out for testing. During the audited 18-month period, the average monthly test volume was 168 (SD 20). The three departments ordering the most RBC folate testing were nephrology (15%), haematology (7%) and oncology (7%). Physician feedback was supportive of the change, and during the 2 months after targeted email correspondence, the average monthly test volume decreased 24% (p<0.01) to 128 (SD 1). On discontinuation of the test in-house and implementation of the pop-up, the average monthly test volume decreased another 74% (p<0.01) to 3 (SD 2). In the 10 months following discontinuation of the test on-site, there were only 39 RBC folate tests performed with no deficiency detected. This initiative significantly reduced unnecessary RBC folate orders. The change in ordering on email contact suggests that physician education was an important factor reducing overutilisation. However, the most significant decrease came from restricting the test so that only orders approved by a biochemist would be performed.

Reduction in Unnecessary Red Blood Cell Folate Testing by Restricting Computerized Physician Order Entry in the Electronic Health Record

PURPOSE

The red blood cell (RBC) folate test is a laboratory test with limited clinical utility. Previous attempts to reduce physician ordering of unnecessary laboratory tests, including folate levels, have resulted in only modest success. The objective of this study was to assess the effectiveness and impacts of restricting RBC folate ordering in the electronic health record (EHR).

METHODS

This was a retrospective observational study that took place from January 2010 to December 2016 at a large academic healthcare network in Toronto, Canada. All inpatients and outpatients who underwent at least 1 RBC folate or vitamin B12 test during the study period were included. Ordering an RBC folate test was restricted to clinicians in gastroenterology and hematology. The option to order the test was removed from other physicians' computerized order entry screens in the EHR in June 2013.

RESULTS

RBC folate testing decreased by 94.4% during the study, from a mean of 493.0 ± 48.0 tests per month prior to intervention to 27.6 ± 10.3 tests per month after intervention (P < .001).

CONCLUSIONS

Restricting RBC folate ordering in the EHR resulted in a large and sustained reduction in RBC folate testing. Significant cost savings, estimated at more than a quarter of a million Canadian dollars over 3 years, were achieved. There was no significant clinical impact of the intervention on the diagnosis of folate deficiency.

Burning mouth syndrome: results of screening tests for vitamin and mineral deficiencies, thyroid hormone, and glucose levels-experience at Mayo Clinic over a decade

BACKGROUND

Burning mouth syndrome (BMS) is a disorder characterized by chronic mouth pain in the absence of objective clinical abnormalities. Vitamin or mineral deficiencies may have a role in BMS, but data regarding the prevalence and relevance of hematinic deficiencies are conflicting. We aimed to determine the frequency of specific laboratory abnormalities in patients with BMS.

METHODS

We retrospectively reviewed the results of screening blood tests in patients with BMS at our institution between January 2003 and December 2013.

RESULTS

Among 659 patients with BMS, the most common decreased values or deficiencies were vitamin D₃ (15%), vitamin B₂ (15%), vitamin B₆ (5.7%), zinc (5.7%), vitamin B₁ (5.3%), thyrotropin (TSH) (3.2%), vitamin B₁₂ (0.8%), and folic acid (0.7%). Laboratory values for fasting blood glucose and TSH were increased in 23.7% and 5.2%, respectively.

CONCLUSIONS

In patients with symptoms of BMS, our results suggest it is reasonable to screen for fasting blood glucose, vitamin D (D₂ and D₃ ), vitamin B₆ , zinc, vitamin B₁ , and TSH. Deficiencies of vitamin B₁₂ and folic acid were rare (<1% abnormal).

Tackling serum folate test in European countries within the health technology assessment paradigm: request appropriateness, assays and health outcomes

Several authors have recently claimed an excess in serum folate test ordering, suggesting phasing out it from clinical use. According to studies performed in countries undergoing folic acid fortification policies, it is indeed no more cost-effective to test folate in the face of deficiency prevalence <1%. In this paper, we sought to evaluate request appropriateness, analytical issues, and cost-effectiveness of serum folate determination for clinical purposes in the European context, considering if evidence retrieved in fortified countries may be generalized. Studies performed in non-fortified countries have generally reported a suboptimal folate intake and suggest a remarkable prevalence of folate deficiency. Our internal data suggest that ~20%–25% of the subjects undergoing serum folate test are at risk for deficiency. However, a reliable evaluation of the risk for deficiency implies the knowledge of all issues related to the total testing process of folate measurement as well as the identification of the appropriate population in which to perform the test. The cost-effectiveness of the test is maximized when the request is oriented to subjects suggestive/at risk for deficiency, becoming low if the test is used as a screening tool or for monitoring of vitamin intake/supplementation. Because the individual folate status has a key role in ensuring normal development, physiologic growth, and maintenance of optimal health, the evaluation of its serum levels has to be retained in the clinical use in non-fortified countries, boosting for more appropriate request, and evidence from countries following fortification policies should be cautionary interpreted.

The Pediatric Methionine Requirement Should Incorporate Remethylation Potential and Transmethylation Demands

The metabolic demand for methionine is great in neonates. Indeed, methionine is the only indispensable sulfur amino acid and is required not only for protein synthesis and growth but is also partitioned to a greater extent to transsulfuration for cysteine and taurine synthesis and to >50 transmethylation reactions that serve to methylate DNA and synthesize metabolites, including creatine and phosphatidylcholine. Therefore, the pediatric methionine requirement must accommodate the demands of rapid protein turnover as well as vast nonprotein demands. Because cysteine spares the methionine requirement, it is likely that the dietary provision of transmethylation products can also feasibly spare methionine. However, understanding the requirement of methionine is further complicated because demethylated methionine can be remethylated by the dietary methyl donors folate and betaine (derived from choline). Intakes of dietary methyl donors are highly variable, which is of particular concern for newborns. It has been demonstrated that many populations have enhanced requirements for these nutrients, and nutrient fortification may exacerbate this phenomenon by selecting phenotypes that increase methyl requirements. Moreover, higher transmethylation rates can limit methyl supply and affect other transmethylation reactions as well as protein synthesis. Therefore, careful investigations are needed to determine how remethylation and transmethylation contribute to the methionine requirement. The purpose of this review is to support our hypothesis that dietary methyl donors and consumers can drive methionine availability for protein synthesis and transmethylation reactions. We argue that nutritional strategies in neonates need to ensure that methionine is available to meet requirements for growth as well as for transmethylation products.

Serum folate levels in schizophrenia: A meta-analysis

To clarify the relationship between serum folate and schizophrenia (SZ) risk, the meta-analysis was conducted. PubMed, Embase, and Web of Science were searched without language restrictions. Weighted mean difference (WMD) as a summary statistic was used in this meta-analysis. Subgroup analyses by publication language (English and non-English), ethnicity (Caucasian, Asian, African, Latino, and mixed population), duration (acute, chronic, patients including both acute and chronic SZ, and not mentioned about either chronic or acute), measurement time (before drugs using and after drugs using), gender (male and female) and age (<50 years old and >50 years old) were performed. Power analysis was also conducted to detect the reliability of the meta-analyses' results. In summary, the subgroups which failed to detect significant decreased associations were always with lower statistic power and could not be confirmed. The results supported that decreased serum folate was associated with SZ risk in total studies and subgroups of English publications, Caucasians, Asians, acute SZ patients, measurement after drugs using in SZ patients, and age<50 with the great enough powers, respectively. In conclusion, the present meta-analysis found that folate deficiency is associated to SZ, and subgroups which did not reach enough statistical power need further investigation in the future.