Lower Patient Cancellation Rates for Elective Surgery
For surgeons and healthcare administrators, surgery cancellations are synonymous with wasted time and money. If uncontrolled, day of surgery cancellation rates can have significant consequences on profitability, clinical flow, clinical efficiency, patient wait times, patient experience, patient health and more. Despite surgery cancellations hindering the success of providers and the patient they serve, strategizing over these rates rarely takes precedence. In a busy environment with a lot of moving parts, it’s tough to take a step back and take real actions to optimize operations. In saying this, as healthcare providers, there are things that you can do today to reduce cancellations and it doesn’t start with you, it starts with the patients.
A study in the Journal of Anaesthesiology Clinical Pharmacology measured the number of cancellations for elective surgery on the day of the operation in a 500 bedded Government hospital. During the 13-month study, 7272 patients were scheduled for elective surgical procedures and 1286 (17.6%) of these surgeries were cancelled the day of. This is an average of 5.5 cancellations per day.
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Here are the main reasons for elective surgery cancellations:
63% were due to lack of availability of Operational Theater (OT) time
19% were due to patients not showing up
11.6% were due to patient medical reasons
1.2% were because the surgeon had to change the surgical plan
2.1% were because the patients weren’t ready
3.1% were due to equipment failure
This study found that majority (63%) day of surgery cancellations were due to a lack of OT time. This can summed up to a shortage of operating time, but includes administrative and logistical causes like not having sterile instruments, clean beds, oxygen or blood delivered etc. As the study explains, a lot of OT time is wasted “due to late starts, time between cases, preparation and cleaning OTs, and delayed transportation of patients to OT.” In other words, with improvements made to scheduling, patching inefficient holes amongst OT staff, speedier clean times etc., a large percentage of cancellations could be potentially overturned.
The second most notable cause for last minute cancellations---and where we’d like to focus the remainder of the article--is due to the patients themselves. 32.7% of total cancellations in the study were due to patients not showing up, patients having medical reasons that prevented them from being operated on, and patients not being ready. In other words, almost a third of all last minute cancellations are driven by the patient.
This begs the question, how can patient-driven surgery cancellations be improved upon? To answer this, let’s break-down the exact causes of patient cancellations in the first place.
Patient-Related Surgery Cancellation Causes
Here are the commonly cited causes for patient-related cancellations:
- Patient doesn’t show up (e.g. scheduling misunderstanding, lack of communication)
- Patient’s medically unfit (e.g. hypertension, diabetes uncontrolled, anemia)
- Patient’s not ready (e.g. forgot to fast the night before)
- Patient’s not showing up with the required materials
- Patient refuses surgery or cancels (due to last minute fears and anxiety)
The most common reason for patient-caused cancellation, cited across numerous studies, is absenteeism. The cause of this absenteeism can be due to disorganization, lack of information, lack of communication between hospital and patient, family or social problems, or anxiety and fear. It can be argued that improving “absenteeism” in patients is more clear-cut than solving for the myriad of factors that result in a lack of OT times. Focusing on the patient as a means to reduce cancellation rates by helping them be more mentally, medically or logistically prepared for surgery is a clear channel for success.
How Care Providers Can Lower Patient Cancellation Rates
1. Address Patient Anxiety and Mental Preparedness
In a study published in BioMed Central, anxiety levels of 239 patients scheduled for surgery were collected. The study found that “significant preoperative anxiety was seen in 70.3% patients”. The study found that the most common factors leading patient anxiety were “fear of death (38.1%) and fear of the unknown (24.3%). If “fear of death” can be measured in 64 out of 239 patients, you can bet that if left uncontrolled, patients will cancel surgery due to anxiety.
There is significant data to suggests that the mental state of a patient can predict surgical outcome and recovery--not just their rate of cancellation. In fact, there’s a positive correlation between patients with measurable pre-op anxiety or depression and having poorer surgical outcomes, requiring more revision surgery, having greater post-op pain, and costing the provider more financially.
The Journal of Arthroplasty found that “the cost of a total knee replacement for a patient with measurable anxiety or depression was $3420 higher than those without.” Patients going into surgery with anxiety or depression often require additional care, longer rehab, and have more complications in recovery.
As a healthcare provider, there are numerous drug-free alternatives that are proven to cut down on patient preoperative anxiety. One of the most successful means to reduce anxiety is through “mindfulness meditation” during PreHab. In a patient-focused preoperative mindfulness meditation program, patients are taught to let go of stress and anxiety, focus on the present, and gain new methods of dealing with pain and irrational thoughts.
In PeerWell’s PreHab program, mindfulness meditation is incorporated into daily plans for those awaiting joint replacement surgery. Joint replacement recipient, Allan, describes mindfulness meditation having a profound affect on his mental preparedness, “I was rather skeptical of at first...Obviously everyone is worried about these things and the mindfulness exercise prepares you for the hospital. Mindfulness was very relaxing and very useful...I did find myself in hospital going through the mindfulness breathing exercises."
By offering a wide-range of tools to deal with anxiety, like mindfulness meditation during PreHab, patients will be better equipped to deal with their inevitable pre-op jitters which can drive down cancellations and absenteeism.
2. Better Pre-Operative Guidance and Communication
By empowering patients to have a stake in their upcoming surgery, they’ll feel in greater control over the procedure. Having patients engaged and advocating for their health undoubtedly makes the providers job easier and can help open up the lines of communication between patient and provider.
Dr. Chabner, a Radiation Oncologist, explains, “Give patients things they can control. This way, they’ll feel like they have some ability to affect their own outcome by their own preparation. By doing this, you’re giving them 90% of the workload and you can really enhance patient confidence. Don’t send them away with less information, send them away with as much as you can. They won’t be in the dark, they’ll be empowered.”
Guiding patients through their pre-op preparation by giving them a checklist of tasks to complete or offering an interactive PreHab program will help patients to stay focused on their elective surgery. Leveraging a patient engagement app, like PeerWell’s mobile PreHab program will alert the care team of patient progress while counting the patient down to surgery day. Patients feel more engaged in the process, and are less likely to cancel last minute, show up mistakenly unprepared, or feel mentally and physically unready come due day.
3. Hold Pre-Op Assessment Clinics
Offering patients the feeling of preparedness is one of the best ways to avoid controllable patient-related surgery cancellations. Preparation for surgery is mental, physical, environmental and logistical and touching on how a patient can prepare in a pre-op assessment clinic in the days or weeks leading up to surgery will help prep patients for an elective procedure.
A study published by The Surgeon, "The impact of pre-operative assessment clinics on elective surgical case cancellations", found that the “establishment of a pre-operative assessment clinic reduces elective case cancellations”. Specifically, these pre-op clinics showed a “significant reduction in cancellations for medical reasons.” In other words, a pre-op assessment clinic will reduce cancellation rates--especially when it comes to cancellations caused by medical or clinical reasons (like uncontrolled diabetes, weight gain, depression etc.).
When it comes to curbing high cancellation rates, starting with the patients themselves and working your way out is clear path to success. In addition to reducing cancellation rates, offering greater guidance and support throughout the pre-operative period delivers significant side effects. Specifically, using a PreHab program, like PeerWell, can not only improve cancellation rates but creates healthier patients, who are better prepared for surgery, who are more satisfied with the care they’ve recieve.
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