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

Ismail, Ola Z.; Chin‐Yee, Ian; Gob, Alan; Bhayana, Vipin; Rutledge, Angela C.

doi:10.1136/bmjoq-2018-000531

Cited by 7 publications

(4 citation statements)

References 31 publications

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“…Reductions in provincially funded RBC folate testing are also occurring in Ontario (Ismail et al . 2019).…”

Section: Discussionmentioning

confidence: 99%

Red cell folate status among a subset of Canadian children with Down Syndrome post‐fortification

Jory

2022

J intellect Disabil Res

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Background Trisomy 21 or Down Syndrome (DS) is associated with altered methylation pathways. Children with DS may therefore represent a population subgroup with vulnerability to increased exposures to folic acid, which is involved in one-carbon metabolism. Folic acid (FA) fortification of flour and maternal FA supplementation are intended to reduce neural tube defects related to folate deficiency. The interventions have been widely successful in Canada. Emerging evidence suggests that higher FA exposures may also have potential negative consequences, including implications for DNA methylation. This retrospective chart review provides insight on the red blood cell (RBC) folate status of a subset of Canadian children and infants with DS, post-fortification. Methods Children with DS in two Canadian provinces were assessed in the community. Access to RBC folate testing was variable, limiting sample size to 39 (n = 27 for children ≤6 years; n = 12 for children 6-18 years). All children with DS and an RBC folate result were included. The use of FA-containing supplements and formula was documented.Results Among children 6-18 years, 100% had RBC folates >1000 nmol/L, 50% were >2000 nmol/ L and 25% had levels above the upper laboratory reporting limit. Among the younger children (<6 years), 52% had RBC folates >2000 nmol and 2 children exceeded 3000 nmol/L. Among exclusively breast-fed infants (<12 months), 100% had RBC folates >1000 nmol/L and 50% had levels >2000 nmol/L, suggestive of in-utero or maternal exposures. RBC folate status among this subset of Canadian children with DS is higher than documented for the larger Canadian population, and higher than among US children with DS. Conclusions Young Canadian children with DS demonstrated high post-fortification RBC folate status. RBC folate status was higher than reported for the larger Canadian population, and higher than for US children with Down Syndrome. Consumption of folic acid-containing formula and/or supplements was relatively low among these Canadian children with DS, suggesting maternal FA supplements and/or FA-fortified foods may be important etiological factors. A larger, prospective study is needed to validate these results, and to explore potential health implications among this vulnerable population.

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“…Reductions in provincially funded RBC folate testing are also occurring in Ontario (Ismail et al . 2019).…”

Section: Discussionmentioning

confidence: 99%

Red cell folate status among a subset of Canadian children with Down Syndrome post‐fortification

Jory

2022

J intellect Disabil Res

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“…Some studies revealed that applying guidelines and policies of intervention caused a significant reduction of inappropriate requests for laboratory tests ( Ismail et al, 2019 , Pelloso et al, 2016 ). Regrettably, guidelines related to folate and Cobalamin evaluation are widely variable and range from recommending tests for screening of some diseases like dementia to restrictive strategies ( Devalia et al, 2014 , Folate Testing, 2015 ).…”

Section: Discussionmentioning

confidence: 99%

Clinical Appropriateness of Serum Folate ordering pattern in a tertiary care hospital in Saudi Arabia

Alkhaldy

Alqahtani

Alamri

et al. 2020

Saudi Pharmaceutical Journal

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Folate, also known as vitamin B9, is a co-factor necessary for DNA synthesis. Folate deficiency is associated mainly with hematological findings including megaloblastic anemia and pancytopenia. Many countries have mandated grain fortification with micronutrients including folic acid resulting in a reduced prevalence of folate deficiency. Saudi Arabia imports most of the grain products and folate is usually added after milling. There are no local studies to address the folate deficiency prevalence. In this study we aimed to analyse the clinical appropriateness of ordering practice of serum Folate level. Method We reviewed all serum folate requests received at our laboratory in Aseer Central Hospital over one-year period (July 2018 June 2019). We collected patients’ demographics from the electronic requests along with biochemical results of serum B12, ferritin and CBC results. We assessed appropriateness of orders against pre-specified criteria and applied statistical tests to explore for any association or significance. Results Serum folate requests from 614 patients were received during the study period. Serum B12 (543, 88%), and serum ferritin (511, 83%) were concurrently requested. The most common reason for request, when available, was anemia. Anemia was present in (313, 51%) of the subjects for which microcytic anemia was predominant (199, 63.5%), followed by normocytic anemia (101, 33%) and only 10 subjects had macrocytic anemia (3.2%). The most common hematinics’ deficiency was ferritin (30%) followed by B12 (17.2%). Serum folate deficiency was low, observed in only 2.8%. Low folate levels were not significantly different between the group with anemia and the normal hemoglobin group. Conclusion This study identifies a commonly inappropriate serum folate ordering practice that includes ordering all hematinics at the same visit without considering the possible anemia etiologies. The excessive requests might be related to doctors attempt to avoid multiple blood extractions and to try to reduce the time for diagnosis. These policies are generating unnecessary costs and time loss. Education, phasing out or restricting some tests and introducing laboratory policies like sample storing could help reduce unnecessary requests.

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“…B12 in human serum 00 TOSOH ALA system analyser) and immunoassay method by AIA-2000 Automated Immunoassay Analyzer. Vitamin B12 deficiency was diagnosed if the serum vitamin B12 concentration was < 173 Pg /ml (13) .…”

Section: Methodsmentioning

confidence: 99%

Association of Metformin Use with Vitamin B12 Deficiency in Iraqi Patients with Type II Diabetes Mellitus

Diyar F. Atabi,

Qasim,

Kareem Mohammed

et al. 2021

Indian Journal of Forensic Medicine & Toxicology

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Objective: To evaluate the association of metformin use with vitamin B12 deficiency in Iraqi patients with type II diabetes mellitus.Methods: This is a prospective study conducted among the diabetic patients coming to the outpatient clinic at Al-Zahraa teaching hospital in Al-Kut and Al-Baghdad teaching hospital in the medical city of Baghdad from October to December 2018, the samples taken randomly after taking a short history from each patient. Data concerning age, medical disease including diabetes mellitus, and medications including metformin (average daily dose and duration of use) at the time of vitamin B12 measurement were collected. Our patients were classified into 2 groups: diabetic patients taking metformin, diabetic patients not taking metformin. The statistical analysis was done using the SPSS 23 statistical package to analyze the data. The two groups were compared by Paired Samples t-test. Data are presented as the number, percentage, mean value, and standard deviation. The p-value < 0.05 was taken as significant.Results: Vitamin B12 level in diabetic patients who have been on metformin for ≤ 1 year at a dose of ≤ 1 gm/ day showed a significant difference with those patients with no history of metformin use. Conclusion:Low levels of vitamin B12 are related to a longer period and a higher dose of metformin use.

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

Cited by 7 publications

References 31 publications

Red cell folate status among a subset of Canadian children with Down Syndrome post‐fortification

Red cell folate status among a subset of Canadian children with Down Syndrome post‐fortification

Clinical Appropriateness of Serum Folate ordering pattern in a tertiary care hospital in Saudi Arabia

Association of Metformin Use with Vitamin B12 Deficiency in Iraqi Patients with Type II Diabetes Mellitus

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