Wednesday, October 8, 2014

No more folic acid

Although tangetial to nephrology in some ways, I believe a recent study published in JAMA Internal Medicine has important lessons for anyone involved in clinical medicine and should make us think about the things that we do reflexively without really thinking about the reasons.

In 1998, the US government mandated that all cereals be fortified with folic acid. Prior to this point, folate deficiency was a real problem. Now, not so much. In fact, folate deficiency has pretty much disappeared as an important clinical problem. Researchers at the Beth Israel Hospital in Boston examined their clinical database to see whether or not this change had lead to any difference in the number of folic acid tests performed and if the number of low serum folate diagnoses was substantial. The results are fascinating. There was no change in the pattern of ordering this test over the 11 year period covered by the paper. In total, 84,000 tests were performed of which 47 (0.056%) were low. The cost if this test to the institution is $2, the charge is $128 while medicare reimburses $20 per test. Thus, the cost per positive result was $35,800.

It is clear based on this that routine testing of folic acid levels is inappropriate and yet it is still often ordered as a routine test in working up individuals with anemia, dementia and neuropathies. Alan Wu, in an accompanying editorial suggests that clinical laboratories should retire this test and in fact his institution, San Francisco General, now includes this as a send-out only that has to be clinically justified.

The reflexive ordering of laboratory and other tests is a problem that has only gotten worse with computerization. When I started working, as interns we had to write individual lab requests on paper and leave them on patient's wards. There was an explosion in testing when interns were finally able to order labs with just a click of a button. I wonder what tests in particular in nephrology we should be ridding ourselves of or at least ordering far less often?


Anonymous said...

How about q2hr sodiums on a hospitalized hyponatremic patient, q6-8hr CRRT labs, the billions of PTHs on patients with CKD 3 in clinic, all worthless

Anonymous said...

The variations and inconsistenties of 25-Vit-D levels make this another over-used ordered test in the CKD cohort.

Anonymous said...

urine eosinophils for possible AIN