Cancellation of Elective Cases in a Recently Opened, Tertiary/Quaternary-Level Hospital in the Middle East

Abstract

Case cancellations have a negative financial impact due to revenue loss and the potential costs of underutilized time. The goals of this study at a recently opened hospital in the Middle East were to measure the cancellation rates for elective surgical or endoscopic cases and to identify the reasons for cancellation. During the 1-month study period, 170 (22.4%) of the 760 scheduled cases were cancelled. Cultural norms and patient no-shows on the day of surgery accounted for the majority of case cancellations. Understanding local factors on hospital functions may be vital for organizations expanding into new geographic areas.

Cancellations occurring within 24 hours of the day of surgery are costly. They result in lost revenue and disrupt the throughput of cases in the operating room (OR) suite, which may lead to underutilized time. The incidence of cancellations reported in the literature varies widely, from 2% to 27%.^1–9 A low case cancellation rate is a marker of a well-functioning surgical facility, with studies suggesting that a <5%, cancellation rate is achievable at the best-performing centers.⁹

Institutional, cultural, and socioeconomic factors may affect patient cancellations.¹⁰ Understanding local factors is vital for health care quality improvement efforts, especially for organizations expanding into new geographic areas. Once the specific issues are identified, customized solutions and processes can be applied. These delivery models may include a system for preoperative assessment, clinical decisions systems, and fast-tracking low-risk patients.¹¹ The goals of this case study of a recently opened, tertiary/quaternary hospital in the Middle East were to measure the cancellation rate for elective cases scheduled in the OR and endoscopy suites and identify the major reasons for cancellation.

CASE DESCRIPTION

The institutional review board approved this study and waived the requirement for written informed consent. This manuscript adheres to Standards for Quality Improvement Reporting Excellence guidelines.¹² We conducted a retrospective review of electronic medical records (Epic Systems Corporation, Verona, WI) for cases scheduled for February 1–29, 2016, at the 8 staffed ORs and 1 endoscopy location at the Cleveland Clinic Abu Dhabi, a US-managed hospital in the United Arab Emirates (UAE). A review of electronic medical generated reports showed that cancellation rates have been a consistent problem. February was chosen as the study month because surgical activity had reached a stable level.

A cancelled case was defined as one that was not performed after the schedule was finalized at 12:30 PM the day before surgery. This subset of cases “after the schedule was finalized” was chosen as the relevant cancellation measure because, at that time, staff and resources would have been assigned to the scheduled case. The published Veterans Health Administration classification scheme for cancellation reasons was modified and used to categorize cancelled cases as follows:⁶

• Patient reasons (eg, no-show),
• Workup issues (eg, inadequate workup),
• Financial (eg, no insurance approval),
• Facility (eg, staff unavailable), and
• Other.

The final number of elective cases scheduled for February 2016 equaled 760. Overall, 92% of these cases were outpatients, 53% of patients were male, mean age was 48 years (SD 17.6), and 78% were Emirati; these demographics did not differ significantly whether the case was cancelled or not.

The overall cancellation rate equaled 22.4%, or 170 cases not being performed after the schedule was finalized, divided by total cases scheduled (N = 760). Cancellation rates varied by specialty, ranging from a high of 31% (N = 99 cancelled out of 320 scheduled) in the gastroenterology endoscopy cases, to a low of 9% (N = 2 cancelled out of 22 scheduled) for neurosurgical cases. The cancelled cases totaled 19% of all scheduled minutes (Table).

Table.: Comparison by Institute of Scheduled, Performed, and Cancelled After Scheduled Finalized Case Volume and Minutes, and Cancellation Rates

Of the 760 scheduled cases, 135 (18%) were patients seen in the preoperative clinic, and these had a 13% cancellation rate. A total of 142 (19%) of the scheduled cases had a preoperative phone screening as opposed to a physical visit to the preoperative clinic, and these had a cancellation rate of 20%. The remaining patients who did not have either a preoperative visit or a phone screening were cancelled 25% of the time (Figure 1).

Figure 1.: Cancellation rates associated with presence or absence of preoperative clinic appointment or phone screening.

Among reasons for cancellation, patient reasons accounted for the majority (67%) of those with no preoperative clinic contact at all. On the other hand, for patients seen at the preoperative clinic who were cancelled (N = 18), there appeared to be a trend of decreased percentage due to patient reasons (44%), even though patient reasons still accounted for the majority of cancellations.

Figure 2.: Reasons for cancellation and details for patient reasons for cancellation.

Again, patient reasons represented the majority (66%; Figure 2). Among these reasons for cancellation, the top 3 were: a patient communicates a wish to cancel the procedure (38%); a patient communicates a desire to reschedule the procedure (27%); and a no-show without prior communication (17%). Other reasons for cancellations included preoperative workup issues, such as change in medical status or treatment plan (6%), financial reasons such as lack of insurance approval (5%), and facility reasons such as equipment unavailability (1%).

DISCUSSION

Case cancellations within a day of scheduled surgery increase underutilized OR time and reduce revenues. This is problematic because health care systems aim to achieve optimal matching of workload to staffing and to reduce cancellations as a way of decreasing costs, a tenet of the Perioperative Surgical Home.¹³ The results of this study indicate that a US-managed hospital in the Middle East has a cancellation rate of 22%, with the cancelled cases totaling 19% of all scheduled minutes, further indicating the impact on OR functioning. Approximately two-thirds of the cancellations were due to patient reasons. Other studies have reported perioperative cancellations in the Middle East, with rates ranging from 3.6% to 23%.^14–16 Consistent with our findings, patient factors were cited as the reason for cancellation about one-third of the time.

Our cancellation rate is well above the 35% rate reported in a 2009 study from the Veterans Health Administration.⁶ Here, the “most common single reason for cancellation was ‘patient no-show.’” Similarly, a multicenter German study reported a 14.2% rate.¹⁷ Cultural values and norms vary across the globe. In the UAE, citizens have access to free, publicly funded health care, and as a result, it is uncommon to have an insurance problem as a cause for the cancellation. Furthermore, patients may look at several options for care, and at the last minute, may decide not to have their procedure. There is no specific personal cost to the patient for no-show in the UAE. Each of these factors, specific to health care provision in the UAE, may explain why patient factor cancellations are well above the reported rates in the literature.

Models for addressing specific reasons for case cancellation include preoperative clinics and telephone reminders if cancellations are due to medical reasons, but less so if the barriers are staff unavailability. Patients seen at the Cleveland Clinic Abu Dhabi hospital preoperative clinic did appear to have a lower cancellation rate. Although the initial goal of the study was not to compare cancellation rates, post hoc analysis showed that cancellation rates were lowest for patients seen in the preoperative clinic (13%), followed by those who had a preoperative screening (20%), and 25% if neither occurred. Since even patients evaluated in the clinic had a cancellation rate of 13%, this indicates that the clinic is not addressing all potential cancellation reasons.

Better communication systems may be needed to better educate and notify patients about their surgery. For example, automated or personal phone calls to remind patients of their procedure may help reduce cancellations. In our study, many patients who had received a phone call requested to cancel or reschedule their surgery. This suggests that finalizing the schedule and communicating with patients earlier than 24 hours may give patients more time to plan and may increase the amount of time to reorganize the case schedule if a patient cancels. Future work could focus on whether follow-up calls or patient surveys to no-show patients can elucidate reasons for cancellation, whether failure to speak directly to patients (eg, leaving a voicemail without closed-loop communication) is associated with no-shows, and whether perioperative coordinators who speak the native language reduce cancellation rates.

Several limitations of this study should be considered. First, this is a retrospective study performed at a single institution, and the unique local factors influencing cancellation rates cannot be broadly generalized. Second, it was not possible to determine the exact cancellation reason for 21% of cancelled cases. Finally, there may be selection bias, as patients scheduled for the preoperative clinic or who received a screening call may be systematically different than those who were not.

In conclusion, this case study of a recently opened, US-managed hospital in the Middle East showed that 1 out of 5 elective cases scheduled were cancelled, most often due to patient reasons, including high no-show rates. It may be that local cultural factors are a major contributor for the magnitude and timing of cancellations. The implications of the findings are relevant to health care organizations expanding to emerging health care markets. Conventional OR management solutions may require adaptations to the local setting.

ACKNOWLEDGMENTS

The authors acknowledge the members of the Cleveland Clinic Abu Dhabi Surgical and Procedural Committee and EPIC liaison teams who participated in the project, namely Andrew Kellam, Kelley Thornton, Amira Siyam, Renu Thomas, Deborah Jackson, David Delaney, Lamiae Beneladel, Rajesh Selvanathan, Jithin Nambiar, Jasin Thaj, Antonio Ramirez, Eric Matayoshi, Margaret Hartman, Andrew Patske, Kashif Razaq, Yinka Adekeye, Ryan Cork, and Ralph Jean Mary. Thanks to Erin Maddy from the University of Vermont, Julie Westover from the University of Pennsylvania, and Joseph Sanford, associated with the Stanford Fellowship for Management of Perioperative Services, for their helpful feedback on the manuscript. We also thank Cleveland Clinic Abu Dhabi Chief Executive Officer Tom Mihaljevic, Chief Academic Officer Emin Murat Tuzcu, and Senior Director of Clinical Operations Jonathan McGowens for supporting the conduct and sharing of the research.

DISCLOSURES

Name: Amanda J. Morris, MD.

Contribution: This author helped in designing the study, performing data acquisition and analysis, interpreting the data, and writing the manuscript.

Name: James McAvoy, MD.

Contribution: This author helped in designing the study, performing data acquisition and analysis, interpreting the data, and drafting the manuscript, and this author contributed to its critical review.

Name: Dana Dweik, MHPA.

Contribution: This author helped in performing data acquisition and analysis, and preparing the manuscript.

Name: Massimo Ferrigno, MD.

Contribution: This author helped in conceiving the study, providing technical support, and contributing to its critical review.

Name: Alex Macario, MD, MBA.

Contribution: This author helped in designing the study, made substantial contributions to data analysis and interpretation, helped in writing the manuscript, and contributed to its critical review.

Name: Markus Haisjackl, MD, MBA.

Contribution: This author conceived and designed the study, contributed to its analysis and interpretation.

This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.