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Case Scheduling Preferences of One Surgeon's Cataract Surgery Patients

Section Editor(s): Dexter, FranklinDexter, Franklin MD, PhD*; Birchansky, Lee MD; Bernstein, James M. PhD; Wachtel, Ruth E. PhD, MBA§

doi: 10.1213/ane.0b013e31818f1651
Economics, Education, and Policy: Research Reports

BACKGROUND: The increase in the number of operating rooms nationwide in the United States may reflect preferences of patients for scheduling of outpatient surgery. Yet, little is known of the importance that patients place on scheduling convenience and flexibility.

METHODS: Fifty cataract surgery patients seen by a surgeon at his main office during a 6-mo period responded to a marketing survey. All the patients had Medicare insurance and supplemental insurance permitting surgery at any facility. A telephone questionnaire included four vignettes describing different choices in the scheduling of cataract surgery. Respondents were asked how far they would be willing to travel for one option instead of another. For example, “Your surgery will be on Thursday in three weeks at 2 pm. You can drink water until 9 am. You arrive at 10 am, because your surgery might start early. If you travel farther, you would arrive at 8 am for 9 am surgery.”

RESULTS: The median (50th percentile) additional travel time was 60 min (lower 95% confidence bound ≥52 min) for each of four options: to receive care on a day chosen by the patient instead of assigned by the physician, to receive care at a single site instead of both the surgeon's office and a surgery center at a different location, to combine the examination and the surgery into a single visit instead of two visits, and to have surgery in the morning instead of the afternoon.

CONCLUSIONS: The patients of this ophthalmologist placed a high value on convenience and flexibility in scheduling their surgery. In general, this would be achievable only if many operating rooms were available each morning.

IMPLICATIONS: One surgeon's cataract surgery patients place a high value on convenience and flexibility in outpatient surgery scheduling. If general, this would be achievable only if many operating rooms were available each morning.

From the *Division of Management Consulting, Departments of Anesthesia and Health Management and Policy, University of Iowa; †Fox Eye, Cedar Rapids; ‡Frank N. Magid Associates, Inc., Marion; and §Department of Anesthesia, University of Iowa, Iowa.

Franklin Dexter is editor of Economics, Education, and Policy for the Journal. This manuscript was handed by Steven L. Shafer, Editor-in-Chief; and Franklin Dexter was not involved in anyway.

Accepted for publication August 8, 2008.

Address correspondence and reprint requests to Franklin Dexter, MD, PhD, Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, IA 52242. Address e-mail to or web site

The number of anesthetizing locations in the United States has increased by 15% in the past 3 yr.1 The extra operating rooms (ORs) cannot be explained by the 2% increase in the population2 or by an increase in anesthetics per capita.3 The extra ORs have been associated with a decline in the clinical productivity of anesthesiologists.1,4 Median hours of anesthesia time per anesthetizing location has decreased nationwide 27% in just 3 yr,1 to only 4.3 h per day.*

Statistical methods can be used to guide the decision of when a hospital should open another OR. The mean and standard deviation of the total hours of OR or anesthesia time during 12 consecutive 4-wk periods3,5 are used to calculate a suitable (e.g., 80%) prediction bound for future workload using Student's t-distribution.5 Another OR is staffed if the chosen prediction bound for future workload exceeds some threshold, such as 8 h per OR per day.3,5 The validity3,5 of this method demonstrates the appropriateness of the intuitive approach of staffing another OR when the workday often ends later than desired. The observed growth in the number of ORs in the US marketplace, resulting in clinical workdays averaging 4–5 h,1 cannot be attributed to a lack5–7 of sufficient capacity to provide care within desired waiting times (e.g., average 2–3 wk).8,9

Surgeon preferences may account for the increased number of ORs at many nonprofit hospitals. Coveted first-case-of-the-day starts are apportioned among surgeons using10 loosely enforced rules.11 The resulting never-ending, noncooperative scramble for reserved start times results in growth in the number of ORs11,12 and even growth in OR workload13. Hospitals can function in this manner because most do not need to make a profit, just operate without loss.13–15

The financial return from surgery16–19 may not be the only factor accounting for the rapid increase in the number of ORs at for-profit ambulatory surgery centers in the United States.20 Investors in these centers, including surgeons, may be building new ORs based partly on patient preferences for case scheduling. Previous studies of relationships between case scheduling and patient choices of where to undergo surgery have involved inpatient procedures.21–24 We report a unique8,9,25 survey of patient preferences for scheduling of outpatient surgery.

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A marketing research firm, Frank N. Magid Associates (Marion, IA), surveyed a surgeon's patients to learn the importance they placed on potential improvements to his services achievable by opening an ophthalmic surgery center adjoining his office.

The survey population was the 193 cataract surgery patients seen by the surgeon at his main office during the 6 mo starting May 1, 2007. These patients had both Medicare and supplemental insurance permitting surgery at any facility. The marketing research firm attempted to contact all patients by telephone during the evenings of Monday, December 10, through Thursday, December 13, 2007. Among the potential respondents, 50 answered the questions posed, 49 chose not to participate, 39 were called at least three times without an answer, 14 began the interview but discontinued without providing responses, 13 requested to be called back, 11 had telephone numbers that were nonworking, 7 were on the research firm's “do not call” list, 6 reported that no one currently living at the called number matched the name on the list, and 4 had answering machines that picked up at least three times. The response rate was likely reduced because the survey was performed 3 wk before the Iowa 2008 caucuses. Patients may have been irritated by incessant phone calls inquiring about their political views. The number of responses to each question ranged from 48 to 50.

Four vignettes in the questionnaire described different choices in the scheduling of cataract surgery. Respondents were asked how far they would be willing to travel for one option instead of another. The vignettes are reproduced with permission (© 2007 Frank N. Magid Associates).

First, patients may prefer to choose the day of their surgery:

“You have an eye exam. You need surgery. The next opening near your home is 9 am in three weeks on a day picked by [surgeon's office's name]. If you travel farther, you can choose the day.”

The method used to select the date of elective surgery strongly influences the number of ORs needed.8,10 The baseline of 3 wk was based on two prior survey studies showing that 2 to 3 wk were median acceptable waiting times for outpatient surgery.8,9

Second, visually impaired patients, such as the survey respondents, may prefer to have all work performed at a single site instead of having to navigate to a different, unfamiliar place:

“You have an eye exam. You need surgery. It can be done at a hospital near your home. If you travel farther, it can be done at the office where you had your exam.”

The comparison between a hospital and an office was not a confounder, because the type of facility has a negligible influence on patients' preferences for where to undergo surgery.25

Third, patients may prefer a single visit to multiple visits:

“Your optometrist tells you that you have cataracts. A visit is set up at [surgeon's office's name] for the next week at 9 am on a day that you pick. If [surgeon's name] suggests surgery, it would be at 9 am in three weeks on a day picked by [surgeon's office's name]. If you travel farther, you can have both the examination and surgery done on the same visit.”

Although the patient and driver save one visit in this vignette, actual savings are larger. Seven visits are common for surgery on both eyes: i) ophthalmologist for consultation and evaluation, ii) surgery on one eye, iii) check of intraocular pressure and slit lamp examination of the surgical eye on the first postoperative day, iv) examination on the sixth to tenth postoperative day, v) second surgery, vi) check on the first postoperative day, and vii) examination on the sixth to tenth postoperative day. Instead, care can be provided in just three visits26–28: (i, ii, iii); (iv, v, vi); and (vii). Resulting clinical outcomes associated with fewer visits, including patient satisfaction with the time available to decide whether or not to proceed with surgery,28 are the same28–30 or better.31

Fourth, patients may prefer surgery in the morning:

“Your surgery will be on Thursday in three weeks at 2 pm. You can drink water until 9 am. You arrive at 10 am, because your surgery might start early. If you travel farther, you would arrive at 8 am for 9 am surgery.”

Patients having surgery in the morning have less anxiety and smaller increases in heart rate and blood pressure than patients undergoing the same procedures in the afternoon.32 The respondents may have realized this difference between morning and afternoon surgery, having all recently undergone surgery. The respondents may have also anticipated that they and their drivers would wait less if surgery were scheduled in the morning rather than the afternoon. The fasting and arrival times for 2 pm surgery were calculated using appropriate statistical methods to ensure that the patient would be ready if the surgeon completed preceding cases early.33,34

Each vignette had a Flesch-Kincaid fourth-grade reading level (Microsoft Word 2003, Redmond, WA). Respondents were asked: “For a typical week during the summer” … “would you travel one extra hour for the” alternative presented. If “No,” they were asked if they would “travel 45 minutes for that option.” The travel time was decreased in 15 min increments to 0 min. If “Yes,” they would travel one extra hour, the next question asked if they “would travel an hour and a half,” and finally would they “travel two hours for that option.”

Travel times were reported as medians ± quartile deviations. The nonparametric Hodges-Lehmann method was used to calculate lower 95% confidence bounds for median travel times. We studied the medians because the distribution was leptokurtic. The Mann–Whitney test was used to test for associations between responses and the three other pieces of information: whether “the person bringing you home from surgery” would “be taking off work,” residence within the county of the surgeon's office, and gender. Two-sided P values were calculated using Monte-Carlo simulation to the nearest 0.001 (StatXact-7, Cytel Software, Cambridge, MA).

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For all vignettes, additional travel times for the options presented were 60 ± 30 min and lower 95% confidence bounds for medians were ≥52 min. Means were 56, 58, 59, and 55 min.

Most respondents valued some options but not others. The range of responses was wide for many respondents. The median range for an individual respondent was 30 ± 28 min. Only 3 of 50 respondents answered 60 min for all scenarios.

For each vignette, responses were not associated with whether “the person bringing you home from surgery” would “be taking off from work” (28%, P > 0.53), whether the respondent lived in the county of the surgeon's office (48%, P > 0.30), or whether the respondent was male (52%, P > 0.18).

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In the metropolitan area served by the surgeon, driving time from one edge of town to the other is <45 min. Thus, the median of 1 h extra travel time is a very long time for the respondents. This surgeon's patients place a high value on receiving care on a day chosen by the patient, at a single site, during a single visit, with surgery in the morning. Accommodation of these preferences for convenience and flexibility necessitates ORs that are staffed in the mornings and empty in afternoons. Anesthesia groups can adapt by optimizing their clinical and nonclinical use of anesthesia providers later in the afternoons.4,10,18,19,35–37

The respondents composed one market segment for surgery.22 All patients were treated by one surgeon. All underwent the same procedure. All had Medicare supplemental insurance that paid for care regardless of where or how cataract surgery was scheduled. Almost all were from one geographic area. Travel times were all elicited from the same starting point of “one extra hour.” Research studies would be useful to understand the impact that such patient scheduling preferences may have on decisions to build more ORs.

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*4.3 h = [(median 4300 physician time units per site per year) × (1/4 time units per hour)]/(250 workdays per year).1.
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