# Rising trends on folic acid test requests in a middle-income large academic hospital: A low-value care target for improvement

## TL;DR

This study shows that folate testing is increasing in a large hospital, but most tests are unnecessary and costly.

## Contribution

The study identifies rising low-value folate testing trends and their financial impact in a middle-income hospital.

## Key findings

- Only 0.7% of folate tests showed low results (< 3 ng/mL).
- 74.8% of patients had multiple folate tests ordered, often within three months.
- Over $600,000 was spent on low-value folate testing over five years.

## Abstract

•Folate test ordering is rising in this large academic hospital.•Only 0.7 % of folate tests have results in the low range (< 3 ng/mL).•Most patients had more than one test ordered (74.8 %), many within three months.•Non-clinical guided test ordering suggests low-value testing of folate.•Almost $600 K dollars were spent on low-value folate ordering over 5-years.

Folate test ordering is rising in this large academic hospital.

Only 0.7 % of folate tests have results in the low range (< 3 ng/mL).

Most patients had more than one test ordered (74.8 %), many within three months.

Non-clinical guided test ordering suggests low-value testing of folate.

Almost $600 K dollars were spent on low-value folate ordering over 5-years.

To evaluate the trends in serum folate test ordering and their abnormal results.

The authors retrieved data from an anonymized laboratory database from a single, large, academic hospital from Brazil. The authors retrieved serum folate test results, the number of repetitions and other laboratory measurements obtained in the same time window, ordering setting and clinic. The authors then evaluated the trends in test ordering, and prevalence of low (< 3 ng/dL) results, and assessed targets for improvement in test ordering.

From January 1st, 2018, to December 31st, 2022, 181,379 folate tests were ordered from 82,052 patients, with 0.7 % of low results, rising from 33,988 in 2018 to 44,187 in 2022. The outpatient setting was the most frequent (89.5 %). The clinics that most frequently ordered folate tests were Gastroenterology (33 %) and Nephrology (9.8 %). Most patients had more than one test ordered (74.8 %). The 135,787 re-tests were performed in 36,300 patients. Many exams were repeated within three (22,570) or six months (46,881). Only 24,243 repetitions were made more than a year after the prior exam.

Folate test ordering is an increasing trend in this large academic hospital, suggestive of non-clinical guided test ordering and low-value testing.