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

Area of Science:

• Clinical Chemistry
• Public Health
• Laboratory Medicine

Background:

• Mandatory folic acid fortification of wheat flour in Canada since 1998 has led to a significant decrease in folate deficiency.
• Previous testing at London Health Sciences Centre (LHSC)/St. Joseph's Healthcare London (SJHC) revealed no folate deficiency cases despite numerous red blood cell (RBC) folate tests.
• High test volumes indicated potential overutilization of RBC folate testing.

Purpose of the Study:

• To implement a quality improvement initiative aimed at reducing unnecessary RBC folate testing at LHSC/SJHC.
• To assess the impact of physician education and a new testing protocol on RBC folate test volumes.

Main Methods:

• Retrospective review of RBC folate tests performed over an 18-month period.
• Physician outreach via educational emails to high-volume prescribers.
• Discontinuation of in-house RBC folate testing, requiring biochemist approval for external testing via a computerised physician order entry system pop-up.

Main Results:

• Initial physician education email resulted in a 24% decrease in average monthly test volume.
• Subsequent discontinuation of in-house testing and implementation of a biochemist approval process led to a further 74% reduction in test volume.
• In the 10 months post-discontinuation, only 39 RBC folate tests were performed, with no deficiencies detected.

Conclusions:

• The quality improvement initiative effectively reduced unnecessary RBC folate test orders.
• Physician education played a role, but restricting access through biochemist approval was the most impactful measure.
• This approach demonstrates a successful strategy for optimizing laboratory test utilization in response to public health changes.