Tackling serum folate test in European countries within the health technology assessment paradigm: request appropriateness, assays and health outcomes

Several authors have recently claimed an excess in serum folate test ordering, suggesting phasing out it from clinical use. According to studies performed in countries undergoing folic acid fortification policies, it is indeed no more cost-effective to test folate in the face of deficiency prevalence <1%. In this paper, we sought to evaluate request appropriateness, analytical issues, and cost-effectiveness of serum folate determination for clinical purposes in the European context, considering if evidence retrieved in fortified countries may be generalized. Studies performed in non-fortified countries have generally reported a suboptimal folate intake and suggest a remarkable prevalence of folate deficiency. Our internal data suggest that similar to 20%-25% of the subjects undergoing serum folate test are at risk for deficiency. However, a reliable evaluation of the risk for deficiency implies the knowledge of all issues related to the total testing process of folate measurement as well as the identification of the appropriate population in which to perform the test. The cost-effectiveness of the test is maximized when the request is oriented to subjects suggestive/at risk for deficiency, becoming low if the test is used as a screening tool or for monitoring of vitamin intake/supplementation. Because the individual folate status has a key role in ensuring normal development, physiologic growth, and maintenance of optimal health, the evaluation of its serum levels has to be retained in the clinical use in-non-fortified countries, boosting for more appropriate request, and evidence from countries following fortification policies should be cautionary interpreted.