Prevalence of Folic Acid Deficiency and Cost Effectiveness of Folic Acid Testing: A Single Center Experience
Authors: Diaz Karina , Na Zhu , Gupta Sorab , Arya Vikram , Martinez Lourdes , Dhaliwal Supreet , Ajdir Nora , Gaglani Bhavita , Ahuja Shradha , Fulger Ilmana 
Published: October 2019

Abstract
Study Objective
According to the National Health and Nutrition Examination Survey (NHANES) data from 2003-2006 the prevalence of folic acid deficiency in the United States has decreased from 16% to 0.5% since the dietary folic acid fortification program started in the late 1990s. Routine testing for folic acid deficiency remains quite common in the workup of anemia, dementia, alcoholism and other high risk populations. The objective for this study were to determine the prevalence of folic acid deficiency in order to analyze whether routine testing for deficiency should be discouraged or targeted to specific patient populations. In addition to this, we want to assess the economic burden that folic acid level testing adds to the high cost of care of our health system.
Methods
Cross sectional chart review of all adults tested for folic acid level from March 2014 to March 2015 from the Hospital and Ambulatory Care Center of the Community Hospital was undertaken. Folic acid deficiency was defined as ≤4ng/dl. Folic acid level were further classified as low (≤10ng/dl ), intermediate (10-20ng/dl) and high (>20ng/dl). Age, race, body mass index, hemoglobin, mean corpuscular volume levels and billing details were recorded of all patients and information was also collected regarding known conditions correlated to the folic acid levels including Vitamin B12 deficiency( <300 ng/dl), dementia, alcoholism, pregnancy malabsorption, sickle cell disease, bariatric surgery, inflammatory bowel syndrome, and drug therapy with HAART (Highly Active Anti-Retroviral Therapy) , TMP-SMX(Trimethoprim/sulfamethoxazole), phenytoin, valproic acid and/or methotrexate (Table 1). Statistical testing using t-test, logistic / linear regressions with α level at 0.05 was used for analysis of data.
Results
A total of 957 charts of patients who were tested for folic acid between March 2014 to March 2015 at our Heath- Care System were reviewed. 413 (43%) patients were male and 544 (57%) were female. There were 394 (41 %) Hispanics, 325 (34%) African American, 202 (21%) Caucasian and 36 (4%) were from other ethnicity. The mean age was 59.7 years and a mean Hb was 11. 6 g/ dl.
Mean folic acid level was 14.5 ng/dl. 16 patients from total of 957 (2 %) had folic acid deficiency with value ≤4ng/dl . Additional results from the study are described in Table 1, Table 2 and Table 3.
Conclusion
The prevalence of folic acid deficiency was 2%, About 33,000 dollars per year were used to identify such a low prevalent disease which can be treated at a low cost (2 cents/day) by oral supplementation. Low levels of folic acid were statistically associated with male sex, African American race, dementia and coexistence of vitamin B12 deficiency. Empiric supplementation of folic acid and possibly limiting testing for folic acid level to this group of patients may represent a more cost effective strategy.

Disclosures
No relevant conflicts of interest to declare.