Empiric Folate Therapy Over Testing for Folate Levels in Macrocytosis
This is really a progressive article with a concept that I support wholeheartedly. Many times I can look at a CBC of a patient who has abnormally high or even normal levels at the high end and treat that patient with Vit B12 and folic acid without sending the patient back to get more blood drawn to check for serum levels. While this seems to make sense from a convenience (no need for additional bloodwork) as well as a cost factor, it is rarely done. This article gives an amazing cost savings of at least $82,900 for the number of patients examined at only two hospitals.
Am J Med 2001;110:88-90,149-150 Empiric supplementation with folic acid for patients with macrocytosis with or without anemia is preferable to routine testing for folate levels, report physicians from the HealthONE Presbyterian/St. Luke’s Hospital in Denver. These investigators recommend that tests for folate deficiency be reserved for patients with persistent unexplained macrocytic anemia. Dr. Andrew R. Robinson and Dr. Jeanette Mladenovic reviewed all serum and erythrocyte folate assays performed during 1996 at three hospitals. Of 2998 folate levels measured, only 68 (2.3%) were low. Only 35 of these abnormal results were noted in the patients’ records, and only 16 of these patients were treated with folic acid. In the investigators’ cost analysis, $89,814 was spent on 1257 folate tests at two of the hospitals. On the other hand, the cost of empiric folic acid supplementation was estimated to be no more than $6914, which would have resulted in cost savings of at least $82,900. Added to the issue of cost effectiveness, according to Dr. Robinson and Dr. Mladenovic, is the unreliability of assays in detecting folate deficiency. Empiric folic acid supplementation would bypass the chance that some patients with true folate deficiency would go undiagnosed and untreated. Editorialist Dr. Nancy Berliner of Yale University in New Haven, Connecticut, points out the “apparent carelessness with which folate level tests were ordered” and the fact that half of the abnormal test results were ignored. She emphasizes, as do the study authors, that empiric folate therapy should be undertaken only after cobalamin deficiency has been ruled out. Dr. Berliner concludes, “Although it appears to be cost effective and clinically sound to choose empiric folate treatment over laboratory testing, such a course presupposes a more informed and conscientious approach to the patient than appears to be the case.”