Overuse of Hematocrit Testing After Elective General Surgery at a Veterans Affairs Medical Center
Objective: To evaluate the clinical usefulness and costs of routine postoperative hematocrit testing after elective general surgery.
Methods: We reviewed charts of all patients who had elective general surgery at New Mexico Veterans Affairs Health Care System, Albuquerque hospital from 2011 through 2014. Demographic data and patient characteristics (eg, comorbidities, smoking/drinking history), estimated blood loss (EBL), pre- and postoperative hematocrit levels, and signs and symptoms of anemia were compared in patients who did or did not receive a blood transfusion within 72 hours of the operation.
Results: Of 1531 patients who had an elective general surgery between 2011 and 2014, ≥ 1 postoperative hematocrit levels were measured in 288 individuals. There were 1312 postoperative hematocrit measurements before discharge (mean, 8.7; range, 1-44). There were 12 transfusions (0.8%) for patients without moderate to severe pre-existing anemia (hematocrit < 30%). Five of 12 transfused patients received intraoperative transfusions and 7 patients were transfused within 72 hours postoperation. No patients were transfused preoperatively. Of 12 patients receiving transfusion, 11 had EBL > 199 mL and/or signs of anemia. Risk factors for postoperative transfusion included lower preoperative hematocrit, increased EBL, and having either abdominoperineal resection or a total proctocolectomy.
Conclusions: Routine postoperative hematocrit measurements after elective general surgery at US Department of Veterans Affairs medical centers are of negligible clinical value and should be reconsidered. Clinical judgment, laboratory-documented pre-existing anemia, a high-risk operation, or symptoms of anemia should prompt monitoring of patient postoperative hematocrit testing. This strategy could have eliminated 206 initial hematocrit checks over the 4 years of the study.
Limitations
The retrospective chart review nature of this study may have led to selection bias. Only a small number of patients received a transfusion, which may have skewed the data. This study population comes from a single VA medical center; this patient population may not be reflective of other VA medical centers or the US population as a whole. Given that NMVAHCS does not perform hepatic, esophageal, pancreas, or transplant operations, the potential savings to both the US and the VA may be overestimated, but this could be studied in the future by VA medical centers that perform more complex operations.
Conclusions
This study found that over a 4-year period routine postoperative hematocrit tests for patients undergoing elective general surgery at a VA medical center were not necessary. General surgeons routinely order various pre- and postoperative laboratory tests despite their limited utility. Reduction in unneeded routine tests could result in notable savings to the VA without compromising quality of care.
Only general surgery patients undergoing operations that carry a high risk for needing a blood transfusion should have a routine postoperative hematocrit testing. In our study population, the chance of an elective colectomy, cholecystectomy, or hernia patient needing a transfusion was rare. This strategy could eliminate a considerable number of unnecessary blood tests and would potentially yield significant savings.
