Decreasing redundant serum folate orders and associated cost by utilizing appropriate computerised provider order entry (CPOE) messaging

From the 2023 HVPA National Conference

Sophia Rokkas MD (Lankenau Medical Center), Loukya Kanakamedala MD, Talar Telvizian MD, Kristin Lohr MD

Background:
Serum folate levels are routinely tested on patients with anemia and altered mental status. Following mandatory folic acid fortification in 1998 in the United States, the prevalence of folate deficiency is the general population decreased to 0.5% from 2.3%. Given the decreased prevalence and now fortification of folic acid in the diet, testing for serum folate does not change management in the inpatient setting and has been shown to be a poor test overall. Testing for serum folate in patients without risk factors incurs increased cost, unnecessary blood draws, and no change in clinical management. Οver a 1-year time period it can cost a hospital between $32,000 upwards to $316,000 for serum folate testing. Regardless of folate level, patients who are at an increased risk for developing folate deficiency should be started on folic acid supplementation this includes, pregnant individuals, alcohol abusers or individuals with hemolytic anemia).

Objective:
To minimize unnecessary testing of serum folate levels. Following implementation of a CPOE message that outlines indications for testing folate serum levels. As a result, the primary goal would be to reduce cost and unnecessary blood draws.

Methods:
Analysis of de-identified patients was performed for inpatients admitted under internal medicine in whom a serum folate level was ordered at Lankenau Medical Center from May 1, 2023- August 1, 2023. EPIC was utilized to track: serum folate level, Hgb level, MCV level. Serum folates ordered before and 3 months after implementation of CPOE message were evaluated. The total study population was 2,973 patients. We will retrospectively review inpatients in whom a serum folate was ordered. All studies were performed at Lankenau Hospital.

Results:
Current results show that among 2,973 patients 560 serum folates (20%) were ordered. Among these only 6.9% were abnormal. Further data shows out of 560 folates there was an abnormal hemoglobin in 95% and MCV was abnormal in 55.7% of them. Data regarding successful reduction in folate ordering following message implementation are currently in process and due to be completed by August 2023.

Conclusions:
Overall the testing of serum folate does not provide as much clinical implication as previously thought. As preliminary data shows, the majority of serum folates that are abnormal is about 6.9%. With the fortification of folate, patients are rarely folate deficient despite abnormal hemoglobin. Additionally those that are high risk for deficiency should be initiated on folic acid supplementation without the need to test levels as it would not change overall management. Prior studies have advocated for the use of reduced folate testing and this study provides a simple method to allow for distribution of recommendations to providers and appropriate advising within the electronic health record (EHR)

Clinical Implications:
With the implementation of a CPOE message more providers would be aware of the guidelines and lack of clinical implication of serum folate testing to reduce hospital costs and unnecessary patient lab draws through a reduction in folate testing.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog