Cancellation of elective surgery: rates, reasons and effect on patient satisfaction
===================================================================================

* Wan Xian Koh
* Rachel Phelan
* Wilma M. Hopman
* Dale Engen

## Abstract

**Background** The cancellation of elective surgeries is a major problem that increases wait times, exacerbates costs and can negatively affect patients, both psychologically and physically. Our objectives were to investigate the reasons for cancellations across specialties at a single centre, to compare these reasons with previous data from the same centre between 2005 and 2009 and to examine how cancellations affected patients’ lives and views of the medical system in cases when the cancellations were potentially preventable.

**Methods** Cancellation records of all elective surgeries scheduled between June 1, 2012, and Jan. 31, 2016, at a medium-sized, tertiary care, academic centre were retrospectively reviewed. We evaluated the rates and reasons for cancellation and interviewed a subset of patients whose surgery was cancelled for a potentially preventable reason (i.e., operating room running late, bed shortage, emergency case took place of scheduled surgery).

**Results** Across 11 surgical specialties, 2933 of 20 881 surgeries (14.0%) were cancelled and of these, 2448 (83.5%) were for administrative or structural reasons. Compared with the data collected previously for general, gynecological and urological procedures, cancellation rates increased from 8.1% to 11.8%. Although patients reported inconvenience, they were generally satisfied with the availability and the quality of the health care they received.

**Conclusion** Consistent with the previous study, our data suggest that most cancellations occur because of administrative or structural processes that are potentially preventable. Targeting these processes may help to reduce cancellations for elective surgeries and thereby improve economic efficiency and patient outcomes.

The cancellation of elective surgeries is a long-standing problem faced by many countries worldwide, including Canada. Operating rooms (ORs) are a major source of revenue and expenditure for many hospitals, and inefficiencies in their use often result in cancellations of elective surgeries.1 The cancellations then, in turn, exacerbate inefficiencies by disrupting the continuity of the workflow and affect provider morale across multiple departments.2 Cancellations also increase surgical wait times, increase costs and can have a major effect on patients and their families.3 Psychological effects include disappointment, frustration and dissatisfaction.3 In Canada’s publicly funded health care system, patients often wait for months for surgery and may have rearranged their lives with caregivers and child care, taken time off of work or travelled long distances, only to have surgery cancelled at the last minute. Delays in medically necessary surgery may also worsen health outcomes.4,5

Cancellation rates reported in the literature are highly variable but can be as high as 39%, with substantial differences depending on hospital type, national health care systems or policies, geographical region, patient population, providers and the perioperative management practices at that particular institution.2,3 Evidence suggests that most surgical cancellations are administrative in nature and are preventable.3 However, to prevent such cancellations, it is first essential to thoroughly understand the reasons for their occurrence.3 Previous work from our centre evaluated cancellation rates and reasons for cancellation across 3 surgical services (general surgery, gynecology and urology) and suggested that each cancellation should be treated as an adverse event, with documentation of the sequence of events that led to the cancellation.6

The objectives of this study are to evaluate the incidence of elective surgery cancellations at a single, tertiary care, academic centre across various surgical services, to identify the most common reasons for cancellation and to compare current data with previous data from the same centre.6 We also sought to interview a subset of patients for whom surgery was cancelled for potentially preventable administrative issues to determine how it affected their lives and views of the health care system.

## Methods

We conducted this study at Kingston Health Sciences Centre (Kingston General Hospital site), a mediumsized (i.e., 471 beds), tertiary care academic teaching hospital in Kingston, Ontario. Using the hospital’s patient management database, we retrospectively reviewed cancellation records of all elective surgeries that were scheduled to occur between June 1, 2012, and Jan. 31, 2016. We collected patient age, sex, American Society of Anesthesiologists (ASA) classification of physical status, estimated case duration, surgical procedure, scheduled surgical date, arrival time at the hospital’s Same Day Admission Centre, time of cancellation and reason for cancellation. Eleven surgical services (i.e., cardiac surgery, dental surgery, general surgery, gynecology, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, thoracic surgery, urology and vascular surgery) were included in the study. Same-day cancellations were defined as any surgery listed on the OR schedule that did not occur on the day it was scheduled.

The patient management database contains 50 different cancellation codes. We reduced these 50 codes to 28 by regrouping similar codes (e.g., combining the codes for “no bed,” “no intensive care unit bed,” “no step-down bed” and “no recovery bed” into 1 code, “bed shortage”). We subsequently reclassified the 28 codes into 3 broad reasons for cancellation: medical (e.g., change in medical condition), patient-related (e.g., patient cancelled) and administrative or structural (e.g., bed shortage). Two investigators independently classified codes; any discrepancy was discussed and subsequently re-evaluated until an agreement was reached.

We compared the results from our study to those of a previous study at the same centre. The previous study included an analysis of cancellation rates for 3 surgical services (general surgery, urology and gynecology) between January 2005 and December 2009.6 Both studies were consistent in their definition of same-day cancellations, defined as any surgery listed on the OR schedule that did not occur the day it was scheduled.6 In the previous study by Leslie and colleagues, reasons for cancellation were classified into patient-related, process-related and structure-related categories.6 Given the differences in classifications between the current and previous studies, we did not draw comparisons between categories. However, we were able to directly compare the frequencies of the most prevalent, potentially modifiable, reasons for cancellation in both studies, including “OR running late,” “standby patient cancelled,” “bed shortage” and “emergency case took place of scheduled surgery.” Patients listed as “standby” were classified as such by the surgical service if the estimated time of booked cases was greater than the OR time available, as predicted by the patient management database or at the discretion of the surgeon.

One investigator (W. X. K.) also conducted a standardized telephone interview to evaluate the effect that the most common and potentially preventable cancellations had on patients’ lives and their opinions of the health care system. We interviewed patients who were 18 years or older and who had a surgery cancelled between June 1 and Dec. 31, 2015, because of a common administrative or structural reason, namely “OR running late,” “bed shortage” and “emergency case took place of scheduled surgery.” We excluded standby patients from the interview, as they were scheduled for surgery later in the day with a warning that their surgery may be cancelled, which could have potentially biased their interview responses. However, we included these patients in the overall analysis, with “standby cancellation” treated as an independent reason for cancellation to allow comparison with the previous study from our centre.6 We chose the dates to ensure that patients were interviewed at least 1 year, but no more than 18 months, after their cancellation. We designed interview questions based on a review of the literature and previous work from the same centre.6 To our knowledge, there are no validated tools against which our interview tool could be validated. However, we circulated the interview among staff at our centre to ensure clarity and revised it accordingly before contacting patients for an interview. This process provided some degree of face and content validity. The first half of the interview documented patient cancellation details (e.g., demographic variables, surgical characteristics) using multiple choice questions. The remainder evaluated patient perspectives according to a 5-point Likert scale.

### Statistical analysis

We completed data analyses using Microsoft Excel and IBM SPSS version 24. Fisher exact tests were used for exploratory analyses to assess the effect of demographic variables and the surgical characteristics surrounding the cancellation on the patients’ life and views of the medical system.

### Ethics approval

This study was approved by the Queen’s University Faculty of Health Sciences and Affiliated Teaching Hospital’s Research Ethics Board (ANAE-286-15).

## Results

The demographic characteristics for patients with surgical cancellations (*n* = 2933), those contacted for a telephone interview (*n* = 175), the respondents (*n* = 72) and non-respondents (*n* = 103) are shown in Table 1. A total of 20 881 elective surgeries across 11 surgical services were scheduled between June 1, 2012, and Jan. 31, 2016. Of these, 2993 (14.0%) were cancelled on the day of surgery (Table 2). Cancellation rates varied according to surgical service. Neurosurgery and vascular surgery had the highest cancellation rates (20.8% and 20.5%, respectively). Gynecology and thoracic surgery had the lowest cancellation rates, both at 10.2% (Table 3).

View this table:
[Table 1](http://canjsurg.ca/content/64/2/E155/T1)

Table 1 
Demographic characteristics of 20 881 surgeries scheduled between June 1, 2012, and Jan. 31, 2016

View this table:
[Table 2](http://canjsurg.ca/content/64/2/E155/T2)

Table 2 
Reasons for cancellation of 2933 surgeries scheduled between June 1, 2012 and Jan. 31, 2016

View this table:
[Table 3](http://canjsurg.ca/content/64/2/E155/T3)

Table 3 
Cancellation rate and reasons for cancellation by surgical specialty and case duration

When limited to the 3 surgical services (general, gynecology and urology) evaluated in the previous study, our cancellation rate was 11.8%, higher than previously reported for the same centre (1544 cancellations of 19 141 surgeries, 8.1%) between January 2005 and December 2009.6 The cancellation rates observed in the current study were also higher for each surgical service individually (general, 13.5% v. 8.2%; gynecology, 10.2% v. 6.8%; urology, 12.1% v. 9.5%).

In our study, 83.5% of the cancellations were for administrative or structural reasons, 8.8% were for medical reasons and 7.8% were because of patient-related factors (Table 2). Of the 2448 surgeries cancelled for administrative reasons, the most prevalent reasons were because the OR was running late (24.9%), because a standby patient was cancelled (19.8%), because of a bed shortage (16.6%) and because an emergency case took the place of a scheduled surgery (11.5%).

Although the rates of cancellations in general surgery, gynecology and urology caused by the OR running late (30.9% v. 29.3%) and by cancelled standby patients (both at 17.2%) remained fairly consistent across the previous and current studies, respectively, cancellations because of emergency cases decreased (13.0% v. 6.3%) and cancellations because of bed shortages increased (7.2% v. 13.4%). Interestingly, and probably for multiple reasons, the volume of surgical procedures in these surgical services has actually decreased since the previous study (320 per month v. 217 per month).

Of the 175 patients who met eligibility criteria and received a telephone call, 72 (41.1%) completed the interview. The mean age of respondents was 58.4 (standard deviation [SD] 15.2) years; 33 respondents (45.8%) were male (Table 1). In total, 61 patients (34.8%) were unreachable and 42 (24.0%) refused to participate. About half of the respondents (51.3%) were cancelled after registration at the Same Day Admission Centre and 38.9% reported having at least 1 surgery cancelled during the previous 5 years (Table 4). Overall, approximately half of the respondents (48.6%) and their family/friends (55.6%) missed at least 1 day of work and more than one-third of patients and their families travelled more than 80 km only to have the surgery cancelled (34.4% and 33.3%, respectively, Table 4).

View this table:
[Table 4](http://canjsurg.ca/content/64/2/E155/T4)

Table 4 
Details of cancellation among interviewed patients

Most respondents (62.5%) reported that the cancellation caused them or their families moderate to extreme inconvenience (4–5 on Likert scale). Overall, however, patients were moderately satisfied (mean 3.2 [SD 1.5]) with the way their cancellation was handled by hospital staff and 29.2% reported being very satisfied (5 on Likert scale) (Table 5).

View this table:
[Table 5](http://canjsurg.ca/content/64/2/E155/T5)

Table 5 
Effect of cancellation on patients’ lives and views of the current health care system among interviewed patients

Although most patients (75.0%) agreed that fundamental changes should be implemented in the current health care system, respondents had varying opinions regarding the establishment of an alternative health care system (mean 2.8 [SD 1.3], Table 5). Twenty-seven respondents (37.5%) were in favour of establishing an alternative health care system, 15 (20.8%) were neutral and 30 (41.7%) disagreed or strongly disagreed with there being a need for one. Overall, patients were satisfied with the availability (mean 3.8 [SD 1.3]) and quality (mean 3.8 [SD 1.1]) of affordable health care.

Age, sex, surgical procedure and administrative reasons for cancellation had no effect on patient reports regarding the cancellation or their attitude toward the health care system in general. However, patients classified as ASA level 3 or 4 were more often dissatisfied with how providers handled the cancellation (*p* = 0.02) and were less often satisfied with the availability of affordable health care (*p* = 0.02) than patients classified as ASA level 1 or 2. The other factors that affected the patients’ lives and views of the health care system included the financial impact associated with the distance travelled for surgeries (*p* = 0.03) and the time off work for patients (*p* = 0.03) and for their family and friends (*p* = 0.01). Patients whose surgeries had been cancelled more than once in the previous 5 years also reported a more negative view of the health care system (*p* = 0.04).

## Discussion

Our overall cancellation rate was 14.0% across all 11 elective surgical services, which is well within the range of that reported in the literature for academic centres (i.e., 6%–39%).3 Cancellation rates attributed to administrative or structural factors (83.5%), which are considered to be largely preventable, are also comparable to those reported in the literature (87%),3,5 but medical (8.8%) and patient-related (7.8%) cancellations account for a smaller proportion than previously reported.5,7,8 This may be explained, at least in part, by the long wait times for elective surgery in Canada, leading to greater patient adherence to the surgical schedule and preoperative instructions.9 Moreover, many centres have implemented presurgical screening clinics near the scheduled surgery date to medically optimize the patient, improve patient compliance with presurgical instructions and offset patient no-shows.10–13 This is supported by the fact that, of the 257 patients cancelled for medical reasons, 61.9% were attributed to changes in their medical condition after presurgical screening.

Similar to other studies,2,7,8 we found that OR delays were responsible for a substantial number of cancellations, both in this study and the previous study from the same centre (31.5% and 29.3%, respectively). A closer look at the current data revealed that only 22% of the OR delays were caused by unexpected surgical complications; in contrast, 78% could be attributed to potentially modifiable logistical factors. One study attributed the main cause of OR delays to surgeons underestimating case duration or turnover time, particularly for shorter procedures.7 Furthermore, the surgeons who consistently underestimated surgical durations had significantly more cancellations.7

An insufficient number of beds also contributed to a substantial proportion of cancellations at our centre, and this problem appears to have worsened since the last report (7.2% v. 13.4%). A perioperative simulation study from Canada identified bed availability as the bottleneck of our health care system.14 The 2017 report from the Fraser Institute found that Canada has the fewest acute care beds per capita of all 27 Organisation for Co-operation and Economic Development (OECD) countries with universal health care.9 According to a discrete event simulation study conducted at Toronto General Hospital, cancellations can be significantly reduced by adding just 2 beds to the surgical ward, although adding any more than 2 did not further improve efficiency.1

The prioritization of emergency cases is another major reason for cancellations of elective surgeries. In the current study, it accounted for 9.6% of the cancellations across all 11 surgical services. However, the decreased proportion of cancellations because of emergency cases since the previous study (13% v. 6.3%), despite the fact that we still do not have a dedicated OR for emergencies, is encouraging. This suggests that there has been some improvement in the management of emergency cases.6

Despite the short notice of cancellations and the prolonged wait times for treatment, interviewed patients were generally satisfied with both the availability and quality of health care. Objectively, despite being the third most expensive health care system, Canada ranks below the OECD average with respect to the availability and accessibility of resources, while generally doing well on indicators for quality of health care.9 This apparent discrepancy between public perception and international performance rankings of our health care system has also been reported elsewhere.15 Our interview revealed a potential explanation for this discrepancy. We found that same-day cancellations (51.3%) had only a minor effect on patients’ negative view of the health care system (mean 2.8 [SD 1.6]), perhaps because the cancellations were handled by the hospital staff in a satisfactory manner (3.2 [SD 1.5], 48.6% reported 4–5 on Likert scale). Our findings are consistent with those of the previous study conducted at this centre, which found that patients were modestly satisfied with the perioperative process despite the fact that approximately half of the cancellations occurred within an hour of the scheduled surgery.6

### Limitations

Our study provides a report of elective surgical cancellation rates, as well as reasons for cancellation reported over time from an academic tertiary care centre. This is important because it serves as a comparison not only for this centre, but also for similar centres within Canada in terms of cancellation rates, reasons and potential starting points for mitigation strategies. However, being a single-centre study, these findings may not be generalizable to other institutions with different demographics and perioperative practices. It may be difficult to accurately compare our study with that done previously since each study evaluated different time periods. Leslie and colleagues6 collected data from 5 complete calendar years (60 mo), whereas our study examined a 44-month period that did not correspond to complete calendar years. We therefore could not account for changes in the coding of cancellations over time or for seasonal fluctuations in surgical volumes and cancellations.

Furthermore, given that data were retrospectively collected, we were unable to verify the reasons for cancellation or evaluate the precipitating factors. Only a small group of patients were contacted for an interview (*n* = 175), of which only 41% responded, potentially resulting in response bias. We chose an interview period of 12–18 months after cancellation to increase the likelihood that all patients had undergone their surgery in an attempt to reduce bias, but 28 (38.9%) respondents had had more than 1 surgery cancelled within the previous 5 years, and the overall cancellation rate was 14.0%, suggesting that responder bias may be present. As a result, the responses collected during the interview can be considered specific only to this small group and cannot be generalized to the entire population of patients with surgeries cancelled for administrative or structural reasons at our centre. Nevertheless, it is encouraging that the demographic distributions (i.e., sex, age and ASA classification) of the respondents and nonrespondents were similar to one another and these appear similar to that of all patients with cancelled surgeries (Table 1).

## Conclusion

The cancellation rates observed in the current study are within the range reported for other academic centres.3 In addition, our results are consistent with the literature in that most cancellations occurred for administrative reasons (e.g., OR running late, emergency case took place of scheduled surgery, bed shortage) that are potentially preventable.3 Previous studies, including the one from our centre, have suggested that thorough documentation of cancellations (and the events leading up to them) is necessary before mitigation strategies can be identified.3,6 The observed increase in cancellation rates provides evidence that same-day elective surgery cancellations continue to impede timely care for patients at our centre. However, the small cohort that we interviewed was still satisfied with the quality and availability of health care, despite the fact that their surgery was cancelled for a potentially preventable reason, suggesting that the provider management of the cancellation can influence how it affects the patient, at least psychologically. Finally, the current data also suggest that potentially preventable administrative or structural issues may be a good starting point upon which to focus potential mitigation strategies.

## Footnotes

*   This paper was presented at the 2018 Canadian Anesthesiologists’ Society Annual Meeting in Montreal, Quebec.

*   **Competing interests:** None declared.

*   **Funding:** This study was funded by the Department of Anesthesiology and Perioperative Medicine, Queen’s University.

*   Accepted April 30, 2020.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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