Q. Should vitamin B12 and folate still be requested simultaneously? Since
cereals are now supplemented with folate, most laboratories typically find that
about 0.6 percent of folate results are below range. For our laboratory, this
means spending about $1,000 to identify one patient with folate deficiency.
Is there a consensus emerging on this problem?
A. It may, in some cases, make sense to order B12 and folate simultaneously.
However, this ordering practice may be a holdover from the days when both tests
could be done simultaneously using radioassays, when the major indication for
testing was the existence of megaloblastic anemia, and when, as you mentioned,
the level of folate fortification of food was lower. Indeed, a recent study
of middle-aged and older adults who did not take vitamin supplements found that
the prevalence of low folate levels (<3 ng/mL) decreased from 22 percent
(1995–1996) to 1.7 percent (1997–1998).1
From a compliance perspective, laboratories should avoid offering B12 and folate
as a profile or panel. If both tests are going to be done, physicians should
have to order them individually, which is how they will be billed.
Even with megaloblastic anemia, there are often clinical indications that would
lead to ordering only one of the two tests. For instance, a vegetarian is much
more likely to have a B12 deficiency, while a patient with poor nutrition is
more likely to have a folate deficiency because the body’s store of folate
is depleted sooner than its store of B12. Vitamin B12 levels are also ordered
for peripheral neuropathies; in such cases, folate levels are not indicated
In reviewing our laboratory’s data, we found that during one week 141
samples were submitted for B12 or folate levels. Both levels were ordered on
77, folate alone on eight, and B12 alone on 56. Furthermore, no folate levels
were less than 6.5 ng/mL, and only one B12 level was less than 200 pg/mL. Even
though virtually all of these values were normal, we should not underestimate
the importance of that finding in helping the ordering physician.
So what should a responsible laboratory do? Physicians need to recognize that
requesting a folate in addition to a B12 doubles the lab’s work (and the
cost to the health care system) for such testing, and that folate deficiency,
in the absence of megaloblastic anemia and poor nutrition, is now rare in the
- Jacques PF, Selhub J, Bostom AG, et al. The effect of folic acid fortification
on plasma folate and total homocysteine concentrations. N Engl J Med.
1999; 340: 1449–1454.
Gary L. Horowitz, MD
Director of Clinical Chemistry
Beth Israel Deaconess Medical Center
Member, CAP Chemistry Resource Committee
Q. Our organization has about 23 clinical pathology laboratories. For our
quality assurance meetings, about 30 supervisors, managers, and pathologists
from all the laboratories meet for one day each month. It has been suggested
that these QA meetings, where major decisions are made, limit the number of
participants by holding smaller preliminary meetings to gather facts. The main
QA conference would then be attended by five or six representative supervisors,
pathologists, and managers, which should shorten the meeting considerably. Is
it possible for a group as large as ours to make decisions and hold meaningful
discussions? Can you offer insight into how the number of attendees affects
the quality of these QA meetings?
A. Your situation illustrates two problems common to all complex laboratory
services and most health care institutions. First, what is an appropriate number
of attendees for a productive meeting? Second, how can we effectively measure
and analyze a laboratory’s performance and processes, communicate and
share perspectives and ideas for improvement, and then follow up with the necessary
changes, all while maintaining operations around the clock? The more time we
spend in meetings, the less time we have to attend to operations. The more time
we spend dealing with day-to-day operations, the less time we have for improving
The number of people who should attend the meeting depends on the meeting’s
design and purpose. If the intent of the meeting is to allow participants to
inform each other of their accomplishments and failures, then size is irrelevant.
However, if you need to hold discussions and seek input from the participants
so you have a working, problem-solving exchange of ideas, then the size of your
group is unwieldy and ineffective. A monthly all-day meeting of 30 individuals
from 23 separate laboratories may be overkill and an inefficient way to address
quality improvement in your environment. Defining an efficient way to change
and improve that process is not easy, however, nor is there necessarily only
one answer. Your suggested changes may be an improvement for your group.
I recommend that you ask all members of your quality team what they think will
work best for your organization and why. Study their suggestions, select the
one that you believe will work best, implement it, and, in true quality improvement
style, try to find a mechanism to measure the improvement. Possible metrics
include total employee hours spent in QA/QI meetings, total employee hours spent
on QA/QI activities outside of meetings, total number of customer complaints
or a complaint per test ratio, total number of QI projects started and completed,
number of objectively improved processes, such as shorter turnaround times,
fewer lost or rejected specimens, lower blood culture contamination rates, or
fewer wristband errors. Once you select your metrics, collect data before the
change is made and then compare it to data collected a year or so after the
change. The data will most likely indicate whether you made the right choice.
Bruce A. Jones, MD
Department of Pathology
Henry Ford Hospital
Chair, CAP Quality Practices Committee