It is common practice to routinely measure postoperative hematocrit levels at US Department of Veterans Affairs (VA) hospitals for a wide range of elective general surgeries. While hematocrit measurement is a low-cost test, the high frequency with which these tests are performed may drastically increase overall costs.
Numerous studies have suggested that physicians overuse laboratory testing.1-10 Kohli and colleagues recommended that the routine practice of obtaining postoperative hematocrit tests following elective gynecologic surgery be abandoned.1 A similar recommendation was made by Olus and colleagues after studying uneventful, unplanned cesarean sections and by Wu and colleagues after investigating routine laboratory tests post total hip arthroplasty.2,3
To our knowledge, a study assessing routine postoperative hematocrit testing in elective general surgery has not yet been conducted. Many laboratory tests ordered in the perioperative period are not indicated, including complete blood count (CBC), electrolytes, and coagulation studies.4 Based on the results of these studies, we expected that the routine measurement of postoperative hematocrit levels after elective general surgeries at VA medical centers would not be cost effective. A PubMed search for articles published from 1990 to 2023 using the search terms “hematocrit,” “hemoglobin,” “general,” “surgery,” “routine,” and “cost” or “cost-effectiveness,” suggests that the clinical usefulness of postoperative hematocrit testing has not been well studied in the general surgery setting. The purpose of this study was to determine the clinical utility and associated cost of measuring routine postoperative hematocrit levels in order to generate a guide as to when the practice is warranted following common elective general surgery.
Although gynecologic textbooks may describe recommendations of routine hematocrit checking after elective gynecologic operations, one has difficulty finding the same recommendations in general surgery textbooks.1 However, it is common practice for surgical residents and attending surgeons to routinely order hematocrit on postoperative day-1 to ensure that the operation did not result in unsuspected anemia that then would need treatment (either with fluids or a blood transfusion). Many other surgeons rely on clinical factors such as tachycardia, oliguria, or hypotension to trigger a hematocrit (and other laboratory) tests. Our hypothesis is that the latter group has chosen the most cost-effective and prudent practice. One problem with checking the hematocrit routinely, as with any other screening test, is what to do with an abnormal result, assuming an asymptomatic patient? If the postoperative hematocrit is lower than expected given the estimated blood loss (EBL), what is one to do?