Tradition Versus Value: Is There Utility in Protocolized Postoperative Laboratory Testing After Elective Colorectal Surgery?

Abstract

Objective:Determine if routine ordering of postoperative day 1 (POD 1) serum laboratory tests after elective colorectal surgery are clinically warranted and valuable given the associated costs of these lab tests.Summary of Background Data:Routine postoperative serum laboratory tests are a part of many colorectal surgery order sets. Whether these protocolized lab tests represent cost-effective care is unknown.Methods:Patients undergoing elective colorectal surgery between January 1, 2015 and December 31, 2017 at our institution were identified. The protocolized POD 1 lab tests obtained as part of the postoperative order set were reviewed to determine the rate of abnormal values and any intervention in response. Costs associated with protocolized laboratory testing were calculated using dollar amounts representing 2017 outpatient Medicare reimbursement.Results:A total of 2252 patients were identified with 8205 total lab test values. Of these, only 4% were abnormal (3% of hemoglobin values, 6% of creatinine values, 3% of potassium of values, and 3% of glucose values), and only 1% were actively intervened upon. The total aggregate cost of the protocolized POD 1 laboratory tests in these years was $64,000 based on Medicare outpatient reimbursement dollars.Conclusions:Routine POD 1 lab tests after elective colorectal surgery are rarely abnormal, and they even less frequently require active intervention beyond rechecking. This results in increased resource utilization and cost of care without appreciable impact on clinical care, and is not cost-effective. Protocolized POD 1 laboratory testing should be replaced with clinically-based criteria to trigger serum laboratory investigations.

Think Twice: De-implementation of Laboratory Testing After Colorectal Surgery

“…In 2008, Stuebing et al 37 performed a study in which they raised awareness of phlebotomy costs to surgeons and surgical house staff via weekly announcements and observed a savings of $54,967 inpatient charges over 11 weeks. In their study, McKenna et al 19 used the Centers for Medicare and Medicaid Services outpatient laboratory fee schedule to estimate a total cost excess of $64,000 for POD1 laboratory tests of approximately 2300 patients. To establish a realistic cost savings estimate, we elected to use inpatient costs to the hospital, which can vastly differ from the generally higher charges to patients.…”

“…34 In 1999, Skenderis et al 35 examined postoperative testing in a cohort of 105 patients with colorectal cancer and found that only 1.4% of laboratory tests required intervention. More than 2 decades later, McKenna et al 19 published their outcomes from investigating specifically POD1 laboratory tests of 2252 patients undergoing elective colorectal surgery. They found that 96% of POD1 laboratory test results were normal, and only 1% of abnormal results required intervention, which led to a practice shift at their institution toward the elimination of routine POD1 laboratory test, except in select patients.…”

“…18 However, the utility of postoperative laboratory testing is not as well explored. In 2021, McKenna et al 19 published a quality improvement (QI) study showing that most postoperative day 1 (POD1) laboratory test results after colorectal surgery are normal. We explored this concept further by implementing a laboratory work de-implementation plan and assessing its long-term impact on length of stay (LOS) and 30-day readmission rates.…”

Intraoperative Fluid Management a Modifiable Risk Factor for Surgical Quality – Improving Standardized Practice

“…AKI within 24 hours after the operation was reported as it is standard practice in our institution to check postoperative creatinine at this time and rarely required rechecking. 15,16 Of note, patients with lacking preor postoperative creatinine were excluded. Prolonged LOS was defined as LOS !7 days.…”

“…The definition of AKI was based on the Kidney Disease Improving Global Outcomes criteria 14 : increase of postoperative serum creatinine ≥0.3 mg/dL compared to preoperative creatinine within 48 hours or ≥1.5 increase from the baseline which is known or presumed to have occurred within the previous 7 days. AKI within 24 hours after the operation was reported as it is standard practice in our institution to check postoperative creatinine at this time and rarely required rechecking 15,16 . Of note, patients with lacking pre- or postoperative creatinine were excluded.…”