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

Abstract

BACKGROUND: Clinically unindicated laboratory testing contributes to low-value care. Most postoperative day one labs after colorectal surgery are normal. However, no published interventions have shown reducing overall postoperative laboratory testing is safe. OBJECTIVE: The aim of this study was 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 including 5 daily labs until discharge. PATIENTS: All adults undergoing colorectal or small bowel surgery formed intervention and non-intervention cohorts based on surgeons who chose to opt-into the study. Pre-implementation (November 2019 – October 2021) there were 545 intervention and 577 non-intervention patients. post-implementation (November 2021 – March 2023) there were 448 intervention and 437 non-intervention patients. INTERVENTIONS: The intervention included 3 postoperative day one labs and subsequent clinically indicated labs. MAIN OUTCOME MEASURES: Outcome measures included laboratory tests and lab-free days. RESULTS: Post-intervention, the intervention group had a 33% reduction in labs per hospital stay, 26% reduction in labs per day, and 49% increase in lab-free days. There was no difference in length of stay (4 v 4; p = 0.79) or readmissions (14.9% v 12.9%; p = 0.39). The non-intervention group had no significant changes in lab work or lab-free days, with no differences in length of stay (4 v 4; p = 0.49) or readmissions (11.1% v 11.0%; p = 0.96). LIMITATIONS: Demographics and complication rate were not reported. CONCLUSIONS: An intervention targeting reflexive laboratory testing after colorectal surgery resulted in safe, significant, sustained reductions in postoperative lab work, with substantial cost savings. These findings prompted a change in the laboratory order set to an opt-out system, and lab 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 at http://links.lww.com/DCR/Bxxx.