Are Routine Postoperative Laboratory Tests Really Necessary After Lumbar Spinal Surgery?

Postoperative laboratory testing in the era of outpatient total joint arthroplasty: Targeted patient selection and associated cost savings

Background

With the advent of outpatient total joint arthroplasty (TJA), the days of routinely drawing postoperative labs (complete blood counts [CBCs] and metabolic panels [CMPs/BMPs]) to monitor for complications are behind us. However, there does exist a subset of at-risk patients that may benefit from diligent postoperative monitoring, though the circumstances under which labs should be ordered remains unclear and subject to surgeon discretion. A systematic review of the literature was therefore conducted to evaluate the utility of postoperative laboratory testing, approaches to targeted patient selection and associated cost-savings.

Methods

The PubMed, MEDLINE, EBSCOhost, and Google Scholar electronic databases were searched on August 17, 2023, to identify all studies published since January 1, 2000, that evaluated the role of postoperative lab testing in TJA. (PROSPERO study protocol registration: CRD42023437334). Articles were included if a full-text English manuscript was available and the study assessed the utility of routine postoperative labs in TJA. 19 studies were included comprising 34,166 procedures. The mean Methodological index for Nonrandomized Studies score was 18.2 ± 1.5.

Results

Abnormal postoperative lab results were common and infrequently required clinical intervention. Among several identified risk factors for patients that may benefit from postoperative laboratory monitoring, preoperative lab values proved excellent discriminators of transfusion requirement and metabolite-associated intervention. Selective testing demonstrated the ability to generate substantial cost-savings.

Conclusion

Routine postoperative laboratory testing offers little clinical utility and produces unnecessary expenditures. Preoperative lab values offer the greatest predictive utility for postoperative transfusion requirement and metabolite-associated clinical intervention, with a preoperative hemoglobin threshold of 111.5 g/L offering an area under the curve (AUC) of 0.93 for predicting postoperative transfusion. Further investigations are needed for metabolic panel predictive models and should incorporate preoperative lab values. The refinement of such models can enable targeted patient selection to avoid unnecessary labs and generate substantial cost savings without compromising patient safety.

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

BACKGROUND

Clinically unindicated laboratory testing contributes to low-value care. Most postoperative day 1 laboratory tests after colorectal surgery are normal. However, no published interventions have shown that reducing overall postoperative laboratory testing is safe.

OBJECTIVE

This study aimed to investigate the impact of reducing postoperative laboratory testing after colorectal surgery.

DESIGN

This is a quality improvement study.

SETTINGS

The study was conducted at an academic center with an enhanced recovery after surgery program that included 5 daily laboratory tests until discharge.

PATIENTS

All adults undergoing colorectal or small-bowel surgery formed intervention and nonintervention cohorts based on surgeons who chose to opt into the study. Preimplementation (November 2019-October 2021), there were 545 intervention and 577 nonintervention patients. Postimplementation (November 2021-March 2023), there were 448 intervention and 437 nonintervention patients.

INTERVENTIONS

The intervention included 3 postoperative day 1 laboratory tests and subsequent clinically indicated laboratory tests.

MAIN OUTCOME MEASURES

Outcome measures included laboratory tests and days free of laboratory work.

RESULTS

Postintervention, the intervention group had a 33% reduction in laboratory tests per hospital stay, a 26% reduction in laboratory tests per day, and a 49% increase in laboratory test-free days. There was no difference in length of stay (4 vs 4; p = 0.79) or readmissions (14.9% vs 12.9%; p = 0.39). The nonintervention group had no significant changes in laboratory work or laboratory test-free days, with no differences in length of stay (4 vs 4; p = 0.49) or readmissions (11.1% vs 11.0%; p = 0.96).

LIMITATIONS

Demographics and complication rates were not reported.

CONCLUSIONS

An intervention targeting reflexive laboratory testing after colorectal surgery resulted in safe, significant, sustained reductions in postoperative laboratory work, with substantial cost savings. These findings prompted a change in the laboratory order set to an opt-out system, and laboratory work reduction approaches have been implemented within other surgical divisions. Continuation and spread of these efforts are instrumental for prioritization of high-value surgical care. See Video Abstract .

PINSELO DOS VECES ELIMINACIN DE LAS PRUEBAS DE LABORATORIO DESPUS DE LA CIRUGA COLORRECTAL

ANTECEDENTES:Las pruebas de laboratorio clínicamente no indicadas contribuyen a una atención de bajo valor. La mayoría de los análisis de laboratorio del primer día post operatorios de una cirugía colorrectal son normales. Sin embargo, ninguna intervención publicada ha demostrado que reducir las pruebas de laboratorio post operatorias generales sea seguro.OBJETIVO:El objetivo de este estudio fue investigar el impacto de reducir las pruebas de laboratorio pos toperatorias después de la cirugía colorrectal.DISEÑO:Este es un estudio de mejora de la calidad.AJUSTES:El estudio se llevó a cabo en un centro académico con un programa mejorado de recuperación después de la cirugía que incluye 5 laboratorios diarios hasta el alta.PACIENTES:Todos los adultos sometidos a cirugía colorrectal o de intestino delgado formaron cohortes de intervención y no intervención basadas en los cirujanos que optaron por participar en el estudio. Antes de la implementación (noviembre de 2019 - octubre de 2021) había 545 pacientes con intervención y 577 sin intervención. Después de la implementación (noviembre de 2021 - marzo de 2023) hubo 448 pacientes con intervención y 437 sin intervención.INTERVENCIONES:La intervención incluyó 3 laboratorios post operatorios del primer día y laboratorios posteriores clínicamente indicados.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron pruebas de laboratorio y días sin laboratorio.RESULTADOS:Después de la intervención, el grupo de intervención tuvo una reducción del 33 % en laboratorios por estancia hospitalaria, una reducción del 26 % en laboratorios por día y un aumento del 49 % en los días sin laboratorio. No hubo diferencias en la duración de la estancia hospitalaria (4 frente a 4; p = 0,79) ni en los reingresos (14,9% frente a 12,9%; p = 0,39). El grupo de no intervención no tuvo cambios significativos en el trabajo de laboratorio o en los días sin laboratorio, sin diferencias en la duración de la estadía (4 versus 4; p = 0,49) o reingresos (11,1% versus 11,0%; p = 0,96).LIMITACIONES:No se informaron datos demográficos ni tasa de complicaciones.CONCLUSIONES:Una intervención dirigida a pruebas de laboratorio reflexivas después de la cirugía colorrectal resultó en reducciones seguras, significativas y sostenidas en el trabajo de laboratorio post operatorio, con ahorros sustanciales de costos. Estos hallazgos provocaron un cambio en el orden del laboratorio establecido hacia un sistema de exclusión voluntaria, y se han implementado enfoques de reducción del trabajo de laboratorio en otras divisiones quirúrgicas. La continuación y difusión de estos esfuerzos son fundamentales para priorizar la atención quirúrgica de alto valor. (Traducción-Dr. Mauricio Santamaria ).

Progressing Towards Same-Day Discharges After Robotic-Assisted Radical Prostatectomy; Safe and Cost Effective to Discharge Without Routine Blood Tests

Introduction

Changing population demographics and the recent SARS-CoV-2 pandemic have forever changed healthcare, with increasing demands on straining systems. The economic cost is yet to be fully realised, with growing concerns around the current system's ability to accommodate the ageing comorbid population. Consequently, a paradigm shift has taken place in healthcare systems, prioritizing cost accountability. In the absence of established guidelines or robust literature, the use of laboratory tests postoperatively is often guided solely by clinician preference. This study presents a retrospective analysis that investigates the utility and cost implications of routine postoperative investigation following robotic-assisted radical prostatectomies. The findings aim to emphasise the importance of evidence-based practices and cost-effective approaches in postoperative care.

Materials/Methods

A retrospective analysis was performed on all robotic-assisted radical prostatectomies (RARP) identified from a single institution between 29th June 2017 to 28th June 2019. This interval was chosen in an attempt to avoid bias or confounding variables associated with the SRS-CoV-2 pandemic. A single clinician conducted a comprehensive medical record review using unit record numbers corresponding to identified procedural codes. Demographics and variables were recorded, including postoperative test results, hospital length of stay and 30-day readmission rates. Patients were assigned to either 'Routine Postoperative tests' (RPOT) or 'No Routine Postoperative tests' (No RPOT) and a comparative analysis was performed. Using the Australian National Pharmaceutical Benefits Scheme (PBS) pricing guide, total expenditure was calculated.

Results

A total of 319 patients were included in the study with an average of 2.5 tests per patient within the first 24 hours. Routine postoperative tests had no bearing on outcomes, with comparable readmission rates between cohorts, and a significantly shorter length of stay in the "No routine postoperative tests" group when compared to the "Routine Postoperative Tests". A total of 1028 tests were performed within the first 48 hours following surgery with expenditure on routine testing totalling $20,516 based on the Australian PBS pricing schedule. Abnormal results were returned on 96% of patients. In the RPOT group, 18 out of the 20 common interventions occurred from 302 RARP. Among the patients in the RPOT group, eight individuals underwent blood transfusions. However, none of these patients met the hospital-specific criteria for transfusion, which require a hemoglobin level below 70 or symptomatic presentation with a hemoglobin level below 80.

Conclusion

The data suggests routine postoperative laboratory has no bearing on re-admission rates, with patients experiencing significantly shorter hospital stays. Furthermore, our results indicate inefficient use of routine postoperative laboratory, with few clinical interventions, frequent abnormal results, and significant accumulative expenses.

The role of routine laboratory tests after unilateral total knee arthroplasty

Background

Recent studies suggest that routine laboratory tests are not required within 1 day after partial knee arthroplasty. In this study, we evaluated the utility of routine postoperative laboratory tests after initial unilateral total knee arthroplasty (TKA) in an Asian population. In addition, we explored risk factors associated with abnormal test results.

Methods

Clinical data of patients who underwent original unilateral TKA between 2015 and 2020 were retrospectively analyzed. Patient characteristics and laboratory test results were recorded. Multivariate binary logistic regression analysis was performed to identify risk factors associated with 3 abnormal laboratory results.

Results

A total of 713 patients, who underwent relevant laboratory tests within 3 days of TKA surgery, were enrolled. Among them, 8.1%, 9.9%, and 3.4% patients with anemia, hypoalbuminemia, and abnormal serum potassium levels required clinical intervention after surgery. Binary logistic regression analysis revealed that preoperative hemoglobin levels, estimated blood loss, and age were independent risk factors of postoperative blood transfusion in TKA patients. On the other hand, preoperative albumin levels, intraoperative blood loss, and operation time were risk factors associated with postoperative albumin supplementation. In addition, lower body mass index (BMI) and preoperative hypokalemia were potential risk factors of postoperative potassium supplementation.

Conclusion

Considering that more than 90% of abnormal postoperative laboratory tests do not require clinical intervention, we believe that routine laboratory tests after surgery have little significance in patients with primary unilateral TKA. However, postoperative laboratory testing is necessary for patients with established risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05509-0.

Re-evaluating the necessity of routine laboratory tests after high tibial osteotomy surgery

BACKGROUND

To assess the utility of routine postoperative laboratory tests for patients undergoing high tibial osteotomy (HTO) surgery.

METHODS

The associations between clinical risk factors and postoperative clinical treatment were analyzed. Additionally, a logistic regression analysis was performed to detect independent risk factors for patients requiring postoperative clinical treatment.

RESULTS

A total of 482 patients with symptomatic isolated medial compartment osteoarthritis from January 2015 to May 2020 were included in the present study and underwent examination by the full set of postoperative laboratory tests within 3 days after HTO surgery. However, only a small proportion of the patients with anemia (3.9 %), hypoalbuminemia (4.1 %), and abnormal serum potassium levels (3.5 %) required clinical intervention after surgery. Binary logistic regression analysis showed that the body mass index (BMI), preoperative hemoglobin level, estimated blood loss and operative duration were independent risk factors for postoperative blood transfusion in patients who underwent HTO surgery, and factors associated with albumin supplementation were female sex and preoperative albumin level. In addition, these results indicated that preoperative potassium was potential risk factor for patients who required potassium supplementation postoperatively.

CONCLUSIONS

Based on the analysis, we conclude that routinely ordering postoperative laboratory tests after HTO surgery is unnecessary. However, for patients with identified risk factors, routine postoperative laboratory tests are still needed.

Routine Basic Metabolic Panels Are Not Needed in All Patients After Primary Total Joint Arthroplasty: An Opportunity for Cost Reduction

BACKGROUND

As the incidence of total joint arthroplasty (TJA) increases, identifying methods for cost reduction is essential. Basic metabolic panels (BMPs) are obtained routinely after TJA. We aimed at assessing the prevalence of intervention secondary to abnormal BMPs after primary TJA and at identifying predictors of the need for postoperative BMPs.

METHODS

We reviewed 802 cases (758 patients) of primary lower-extremity TJA performed from January 1 through December 31, 2018, at our tertiary care medical center. Patient characteristics, preoperative and postoperative BMPs, comorbidities, current medications, and in-hospital interventions were recorded. Age-adjusted Charlson Comorbidity Index (AA-CCI) values were calculated. Institutional costs of 1 BMP and of all BMPs not prompting intervention were calculated. We used multiple regression to identify independent predictors of in-hospital interventions secondary to abnormal postoperative BMPs.

RESULTS

Our institutional BMP cost was $36. A total of 1032 postoperative BMPs were ordered; 958 (93%) prompted no intervention. This equated to $34,488 of avoidable BMP costs. We identified 27 cases (3.4%) requiring intervention secondary to abnormal BMPs. Independent predictors of intervention were preoperative renal dysfunction (ie, abnormal creatinine or glomerular filtration rate <60 mL/min) (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.8-22), number of current nephrotoxic medications (OR, 1.9; 95% CI, 1.3-2.9), and AA-CCI value (OR, 1.2; 95% CI, 1.0-1.5).

CONCLUSION

Routine postoperative BMPs are unwarranted for most patients undergoing primary TJA. Testing may be reserved for those with renal dysfunction, those taking multiple nephrotoxic medications, or those with a high AA-CCI value.

The necessity of routine postoperative laboratory tests in enhanced recovery after surgery for primary hip and knee arthroplasty: A retrospective cohort study protocol

INTRODUCTION

Over the last few decades, the concepts of minimally invasive surgery and enhanced recovery after surgery (ERAS) protocols have been introduced into the field of total joint arthroplasty (TJA), and tranexamic acid (TXA) has been widely used in TJA. Modern-day surgical techniques and perioperative care pathways of TJA have experienced unexpected improvements. Recently, the necessity of the practice of ordering routine postoperative laboratory tests for patients undergoing primary TJA has been challenged, especially in the context of implementation of ERAS protocols in TJA. These studies have consistently suggested that routine postoperative laboratory tests are not necessary in modern-day primary, unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA), and laboratory tests after surgery should only be obtained for patients with risk factors. However, it remains unclear whether routine postoperative laboratory tests after THA and TKA remains justified in the Chinese patient population. Therefore, we developed this study to address this issue.

METHODS AND ANALYSIS

This retrospective cohort study will include adult patients who underwent primary unilateral THA or TKA and received multimodal perioperative care pathways according to ERAS protocols. The following patient data will be collected from the electronic medical record system: patients' demographics, preoperative and postoperative laboratory values, operation time, intraoperative blood loss, TXA use, tourniquet use, postoperative length of stay, and any medical intervention directly related to abnormal laboratory values. The main study outcomes are the incidence of acute anemia requiring transfusion and incidence of hypoalbuminemia requiring albumin supplementation. The secondary outcomes are the rates of acute kidney injury, incidence of abnormal serum sodium level, incidence of abnormal serum potassium level, and incidence of abnormal serum calcium level. These clinical data will be analyzed to determine the incidence of abnormal postoperative laboratory values following primary unilateral THA and TKA; to clarify the frequency of any medical intervention directly related to abnormal postoperative laboratory values; and to identify risk factors that predispose patients to have abnormal postoperative laboratory results.

STUDY REGISTRATION

Chinese Clinical Trial Registry (http://www.chictr.org.cn): ChiCTR1900020690.