A new JAMA Internal Medicine study calls for the end of folate testing, finding that it is overused and that deficiency is rare in outpatient settings given that folic acid has been added to processed grains since 1998. “Although this test generates revenue for medical centers, the goal of providing high-value patient care suggests that serum folate testing should be significantly reduced or even eliminated in the outpatient setting,” the authors write.

Between January 1, 2013, and December 31, 2013, 84,187 serum folate levels were assessed among 77,627 study participants. Just 47 were deficient, 166 were “low normal,” 57,411 were normal, and 26,563 were high.

“In this retrospective review, we determined the rate of serum folate deficiency to be exceedingly low in the outpatient population because only 0.056% of serum folate levels measured were in the deficient range. This finding likely represents the significant reduction in folate deficiency since folic acid fortification began in 1998, in addition to an extreme overuse of serum folate testing,” the study states. Additionally, the study authors analyzed cost, charge, and reimbursements. “The overall costs, charges, and reimbursements were $168,374, $10,775,936, and $1,685, 424, respectively. This amount represents a net surplus of $1,517,050 ($137,913 per year) for the medical center,” according to the study.

Because doctors and medical centers want to provide high-value care, these findings suggest a need to make a “significant reduction,” in or perhaps to eliminate folate testing, “which in fee-for-service payment models would result in a significant loss in revenue to the medical center,” the authors write.

This study’s weakness is that it is retrospective and assesses data from just one institution. As such, it may not be applicable to other institutions or populations.

In a related editorial, “Folate Testing: Time to Retire Your VCR,” author and AACC member Alan Wu, PhD, provides an overview of the historical context for folate testing, as well as the challenges involved in shifting medical practice. “Digital cameras, global positioning systems, smartphones, and MP3 players have replaced film, VHS tapes, and LP records. Like them, it is also time for serum and red blood cell folate testing to end in the post–folate supplementation era,” he writes. “Unfortunately, history has shown that medical practices are much more difficult to reform than social practices. Perhaps the threat of medical malpractice lawsuits is much to blame for reluctance to change as a profession. As such, folate testing continues to be performed in most US hospitals.”

Read Wu’s editorial and the study online.