Tom MacMillan and Rodrigo Cavalcanti
By removing folate deficiency testing from the physician order entry, General Internal Medicine physicians, Drs. Tom MacMillan (L) and Rodrigo Cavalcanti, saved UHN approximately $280,000 in unnecessary testing costs. (Photos: UHN)

In the 1990s, folate fortification of grain became mandatory in the United States and Canada.

To most people this might be an interesting, but unimportant piece of information to squirrel away for a future trivia night. But in the medical community, this fact has an effect: red blood cell folate deficiency – a low level of folic acid in the body that can lead to anemia – is now a rare condition, detected in fewer than one per cent of test samples in patients.

At Toronto Western Hospital, General Internal Medicine (GIM) physicians and clinical researchers Drs. Rodrigo Cavalcanti and Tom MacMillan thought these seemingly mundane findings could have a positive impact in patient care management, while saving the hospital unnecessary costs.

"The folate deficiency test was never particularly accurate, but was the only test available and had become a staple when trying to confirm the diagnosis," says Dr. MacMillan.

"However, with more evidence that folate deficiency is uncommon, we wondered whether a mediocre test should still be used as widely as this one especially considering even a positive result did not always lead to a change to a patient's care."

With the support of the Medical Advisory Committee and collaborator Dr. Paul Yip from UHN Laboratory Medicine, the team used existing UHN research that had demonstrated the low benefit of the red blood folate test, as a springboard to investigate its removal from the physician order entry of the electronic health record. The test was still available for clinicians specializing in hematology or gastroenterology where folate deficiency is more likely among patients.

Physicians could still request the red blood cell folate test, but would have to either fill out paperwork or call the laboratory directly to do so – adding an extra step to force practitioners to reflect on whether the test was necessary.

"This method is known as 'forcing function' where we modify technology to make an unwanted behaviour more difficult to do," explains Dr. Cavalcanti.

"Research has shown education or awareness campaigns that try to get individuals to stop doing something are less successful in changing behaviour, and it's much more effective to directly change the system."

To put this in perspective, in the three-year period before the intervention where researchers gathered baseline data, it was determined only 57 out of 20,214 tests ordered actually met the criteria for red blood cell folate deficiency.

Of those, some might still be an incorrect diagnosis due to the inaccuracy of the test. With each test costing an estimated $14 per order, this amounted to a significant cost for a test that was mostly unhelpful for patients.

In April 2018, the results of the study were published in The American Journal of Medicine. By removing folate deficiency from the system, the research team had not only reduced the unnecessary test by 95 per cent over three years, but also saved UHN an estimated $280,000.

"We are entering an era of healthcare where we need to choose wisely with regard to resources," says Dr. Cavalcanti, who was the principal author of the study with Dr. MacMillan as first author.

"Though removing a test from a system would not necessarily work in all settings, we had data from our own hospital supporting this intervention and we proved red blood cell folate testing doesn't need to be as widely used as it once was."

"The practice of medicine can sometimes get caught up in the belief that we do certain tests or treatments because we've always done them," adds Dr. MacMillan. "But we should constantly evaluate those practices. Whenever we can reduce or eliminate unnecessary testing the benefit is not only to the safety of our patients, but to the system itself."

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