Factors Associated With Cancellation and Delay of Elective Surgery

Evaluating Factors Associated with the Cancellation and Delay of
Elective Surgical Procedures: A Systematic Review
Downloaded from https://academic.oup.com/intqhc/advance-article/doi/10.1093/intqhc/mzab092/6294831 by guest on 16 June 2021

Mona Koushan, M.Sc., Ph.D. Student, Department of Management, Otago Business School,
and Centre for Health Systems and Technology, University of Otago, New Zealand. E-mail:
mona.koushan@postgrad.otago.ac.nz
Lincoln C. Wood, Ph.D., Associate Professor, Department of Management, Otago Business

School, University of Otago, New Zealand, and School of Management, Curtin Business
School, Curtin University, Western Australia. E-mail: Lincoln.wood@otago.ac.nz
Richard Greatbanks, Ph.D., Associate Professor, Department of Management, Otago

Business School, University of Otago, New Zealand. E-mail:
Richard.greatbanks@otago.ac.nz
Corresponding Author: Mona Koushan. Department of Management, Otago Business

School, 60 Clyde Street, Dunedin PO Box 56, Dunedin 9054, New Zealand; Tel: +64 3 479
8133; Fax: +6434798173; Email: mona.koushan@postgrad.otago.ac.nz.
Header: Surgery Cancellation: An SR.
© Crown copyright 2021.

ABSTRACT
Background: Elective surgery cancellation is considered a fundamental problem in health
care services—it causes considerable disruption to patient flow, further eroding often already
stretched operating capacity, and consequentially reduces both hospital performance and

patient satisfaction. This research presents a systematic review (SR) of the reasons for
surgery cancellation among different hospitals and countries. By highlighting these causes,
we identify how to reduce cancellations thereby improving the use of surgical capacity and
resources and create a more predicable patient flow.
Methods: A systematic review was performed on elective surgery cancellation in compliance
with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) and
assessing the methodological quality of systematic review with Measurement Tool to Assess
Systematic Reviews (AMSTAR) guidelines.
Results: There are different reasons for surgery cancellation that vary between hospitals.
This SR demonstrates that hospital-related causes (e.g., unavailable operation room time,
inappropriate scheduling policy, lack of beds) are the primary reason for surgery cancellation,
followed by work-up related causes (e.g., medically unfit, changes in the treatment plan), and
patient-related causes (e.g., absence of a patient, patient refusal).
Conclusion: This review demonstrates the main causes for surgery cancellation can be
controlled by hospital managers, who can aim to improve areas such as patient flow and
capacity management. Ultimately, this will improve the quality of healthcare delivered by
hospitals.
Key Words. Quality improvement, Operation room underutilization, surgery cancellation.
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1. Introduction
Increasing demand for healthcare services with limited resources has led to hospitals paying
more attention to using resources efficiently. While hospitals consist of different units (e.g.,
laboratories, operation rooms (OR), pharmacies, Intensive Care Units (ICU), and recovery

units), the OR units are the most expensive resources (1) and so OR utilization is often
prioritized. Hospital managers exert resources on planning for surgeries and OR resources.
However, unexpected and unplanned events still cause delays or cancellation of elective
surgery (2).
Surgery cancellations carry both financial implications and personal hardship (3). For
instance, when the estimated cost of an OR is US$10 per minute, US hospitals lose between
US$1430 and US$1700 an hour for same-day surgery, depending on the time and duration of
disruptions (4). Additionally, cancellation creates a psychological and financial hardship for
patients and families as their daily life is disrupted (5,6).
To reduce surgery cancellations, the main causes must be identified. Several papers
discuss patients' medical status, surgeon-related causes, and anaesthesiologist-related causes
as some of the main reasons for surgery cancellation. Not all hospitals have similar reasons
for surgery cancellation; one hospital may lack beds in recovery, another may experience
patient no-shows. Therefore, hospitals must develop tailored solutions to use their OR
resources efficiently. Addressing this issue, this research reports on a systematic review that
follows a standard process (7). It investigates the reasons for surgery cancellation among
different hospitals and countries.
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2. Methods
This study presents a systematic review of studies on the causes of surgery cancellations. The
research followed the PRISMA and AMSTAR guidelines for a systematic review (7).
2.1 Search Strategy

The data was drawn from three databases, selected in consultation with a reference librarian:
Web of Science, EMBASE through Ovid, and Medline through ProQuest.
The search terms used in each database differed slightly and used Boolean operators to
ensure effective combinations. To ensure that the research results are reliable, the first author
selected keywords, checked them with the other authors, and added synonyms. To establish
whether the synonyms were applicable and resulted in desirable research outputs, the first
author checked the search terms in three databases with different synonyms. The proportion
of articles and topic relevance were discussed with the other authors and the most applicable
keywords were selected. Table 1 indicates the search term for each database.
2.2 Review Process
In the process of developing a systematic review, the eligibility of studies was established in
two stages. First, to check the exclusion criteria, titles, keywords, and abstracts were screened
twice by the lead author after consensus with two other authors. Second, the full text was
reviewed to follow the inclusion criteria. The first and the second authors finalized the final
list of citations (n=78).
Zotero was used for managing citations, and after inclusion and exclusion criteria were
applied, the articles were entered into an Excel spreadsheet. The quality assessment was
performed following the appropriate quality assessment tool for observational cohort or
cross-sectional studies.
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2.3 Inclusion and exclusion criteria
This review considered only full-text and peer-reviewed articles published before April 2021,
providing a quantitative evaluation (the number of the total scheduled surgery, number of
canceled surgeries, the reasons for cancellation, and the percentage of each of them) for the
cause of cancellation. The studies were excluded if they were in languages other than

English, examined the solutions for a specific reason for surgery cancellation, and considered
the medical methods of the surgery.
2.4 Data Extraction
The search yielded 11,864 articles. After removing articles due to duplication and a lack of
relevance after reading the title and abstract, 186 remained; after reading the whole text
applying the exclusion criteria, 78 articles (the list is provided in Appendix A-Table 3) were
included in the SR (see Figure 1- PRISMA flow chart).
The information extracted included: the first author, journal name, publication year,
country, study period, data collection type, hospital type, number of surgeries per year and
number of canceled surgeries, rate of cancellation, and percentages of different causes of
cancellation. A description of the data is presented in the appendices.
Descriptive analysis included percentages and frequencies for the demographic variables
and indicators of surgical cancellations. The relationship between the numbers of scheduled
surgeries per year (hospital size indicator), hospital type, and the rate of cancellation used
correlation and regression analysis. The reported reasons for surgical cancellation were coded
into one of three primary categories, (1) hospital causes (H) relating to the unavailability of
hospital resources such as beds, clinical staff, OR equipment, and OR management; (2)
patient causes (P) relating to the availability, consent and the financial capability of the
patient; and (3) work-up causes (W) relating to the health condition of the patient to undergo
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the procedure. Within each category, sub-coding was then undertaken (see Appendix C,
tables 6-8).
2.5 Quality assessment
Three different tools were applied to different study types to assess the quality of the eligible

studies in this SR (8). The included studies in this review are categories in observational
research (8), and so we applied the Quality Assessment Tool for Case Series to retrospective
and prospective case studies (9). Critical Appraisal Skills Programme (CASP) (10) was
applied for the qualitative studies (details presented in Appendix A-Table 3). All studies were
rated as “good”, “fair”, or “poor”. The potential bias risks were judged in the overall quality
assessment of the study. Despite the different quality, all 78 studies were considered eligible
for inclusion in the SR. In total, nine studies were counted to have a “fair” quality, with the
remainder achieving “good” quality. A study was ranked as “good” when the study's aim,
research approach, and analysis were clearly described. The studies rated as “fair” included
insufficient information on checklist items, such as the study period (2,11,12) or the
description of method or results (5,11,13).
2.6 Risk of Bias within and across studies
Considering the risk of bias or quality of an individual study to judge the SR's suitability, the
relevant Quality Assessment Tools were completed for all included studies by the first two
authors, independently and blinded. Where assessments were different, the mean score was
calculated. To learn more about the quality of each study, see Appendix A-Table 3.
3. Results
The studies generally used one of two methods to collect the data on surgery cancellation
reasons: 51 retrospective studies (e.g., (6,14,15,16–24)) and 19 prospective studies (e.g.,
(3,13,25–27)). The retrospective study design is more popular and applicable because (1)
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they provide more data at a lower cost, and (2) hospitals record detailed data for each surgery.
Therefore, it is sufficient to use records rather than using the prospective method (e.g.,
observation or questionnaires).
Our results show that about 79% of studies were published after 2010 (See Appendix A-

Table 4). Furthermore, the majority of studies were conducted in university/teaching
hospitals (e.g., (6,16,28–36)) (60%) and public hospitals (e.g., (14,15,18,37,38)) (31%).
These figures indicate that healthcare authorities have increasingly focused on the reasons
and solutions to surgical cancellation in the last decade.
The rate of cancellation varies between hospitals. While some studies indicate the
cancellation rate can range from 5% to 40% of scheduled surgeries (5,39,40), our SR results
indicate this rate is correlated to hospital size and type and can vary from 0.15% (19) to 61%
of scheduled surgeries (41). This huge variation in surgical cancellation rates is evidence that
not only is this a complex managerial problem without a single or standard solution but that
many different causes and contexts—i.e. a multi-factor problem—are likely involved.
Furthermore, results showed an inverse relationship between the hospital size (number of
scheduled surgeries) and rate of surgery cancellation with a correlation of -0.337 discussed in
detail in section 4.2.5.
According to this classification, cancellations are primarily due to hospital causes (44%)
followed by work-up related causes (34%), and then patient-related causes (22%) (see
Appendix D-Figure 4). Despite the avoidability of these causes, hospital-related causes such
as operating room unavailability, scheduling problems, and lack of beds are the main reasons
for cancellation. In the work-up category, medical unfitness and changes in medical status are
the main reasons for cancellation that are unavoidable in most cases. Table 2 provides
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detailed information on reasons for cancellation and their ranks. In Section 4.2, we discuss
causes, applicable solutions, and policies to overcome these problems.
4. Discussion
4.1 Statement of principal findings

In this systematic review of 78 articles, we found that although the main reasons for surgery
cancellation are related to hospital inefficiencies, other factors such as work-up and patient-
related causes also have a considerable effect on elective surgery cancellation.
4.2 Interpretation within the body of literature
4.2.1 Hospital-related causes
Hospital-related causes are the leading cause of elective surgery cancellation and can be
traced to factors such as unavailable OR time; administrative and scheduling problems; lack
of beds, especially in upstream units (ICU and recovery room); and, unavailability of staff
and staff neglect.
The unavailability of OR time is cited as the most significant cause for elective surgery
cancellation, with some studies suggesting it causes more than 50% of surgery cancellations
(26,42–45). While it is an important cause, there are large differences between hospitals. For
example, 78% of surgeries in the Institute of Medical Education and Research in India were
canceled due to unavailability of OR time because of general anesthetic restrictions (44);
however, it was only 0.6% of in Hyvinkää Hospital in Finland (16). Underestimating of
surgery duration by the nurses and surgeons were the most prominent reasons for this cause.
This hospital resolved the problem with the software Opera, which estimates surgery
durations using historical data (16). The unavailability of OR time can also be due to
improper scheduling (44), the overrun of previous surgeries because of unpredictable events
8
such as emergency arrival or prolonging the previous surgery (25), or underestimation of
surgery duration by surgeons (26).
Administrative/scheduling problems and the lack of beds are the most critical causes
following lack of OR time. There tend to be wide variations in between hospitals. Although

Sundaram et al. (11) considered that about 66% of the elective surgery cancellations in a
teaching hospital in the UK were related to lack of beds, just 1.7% of cancellations were
related to administrative problems. Due to the lack of resources dedicated to emergency
cases, the most important reasons for the lack of beds in this hospital were related to
emergency arrivals and acute medical patients. The shortage of beds can also be due to
uncertainties in the length of stay (LOS) in ICU, or the recovery room (11,15). In contrast,
Hand et al. (17) showed that 60% of cancellations in a teaching hospital in the US were
related to administrative problems, and the lack of beds was not an issue for elective surgery
cancellation. The main factor for the administrative issues was unsigned consent forms by
patients as they made immediate decisions about about the surgery. These types of patients'
medical status suddenly became critical so they didn’t have time to consult with their family
or trusted doctor. Providing educational and social services for these patients can generate
quicker decisions. Furthermore, Palter eta al. (41) showed 61% of surgery cancellation is
related to scheduling problems while only 4.5% of cancellation is related to lack of beds.
Scheduling problems leading to cancellations are commonly caused by delays from a
previous case affected following cases. This delay can be due to underestimating the surgery
time, patients' unpreparedness for surgery, and patient delay (41). A retrospective study of
electronic scheduling implementation at a Veterans Affairs Medical Center (USA) showed a
significant drop in the rate of surgery cancelation (28%) and increasing operating room
utilization (35).
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Regarding emergency arrivals, the process often involves separating the elective and
emergency services by providing emergency surgery at a different site or by sending the
emergency cases to a nearby hospital, to avoid slowing the flow of electives. Instead of this,
better management strategies can be applied to not disrupt the flow of electives. This view is
supported by hospital planning authorities in opposition to the separation and suggest that

proper resource management can minimize disruptions.
4.2.2 Work-up related causes
Changes in patient medical status, the treatment plan, and anesthesia work-up all led to
cancellations. In some hospitals, more than 50% of cancellations were related to changing
medical status and medically unfit (6,17,18,48–51). For instance, 70% of cancellations in a
University hospital in China related to patients’ change in the medical status (19).
Pre-assessment clinics are commonly used to address work-up related cancellations and
whether the patient is medically unfit. Knox et al. (52) declared that clinics could reduce the
cancellations due to being medically unfit (from 24% to 10%). However, Dimitriadis et al.
(15) disagreed and noted that despite a well-equipped pre-assessment clinic at Wexham Park
Hospital in the UK, medically unfit patients remained a primary reason for cancellations.
4.2.3 Patient-related causes
Factors such as the patient’s absence, refusal, financial problems, or inadequate preparation
before the surgery can cause cancellations. Most studies mentioned patient absences or
refusal as common reasons for surgery cancellation, where Kim and Lee (3) announced that
47% and 57% of surgery cancellations are related to these reasons, respectively. A
preoperative telephone confirmation of patient attendance decreases non-attendance by 10%
to 1.6% (53). Charging patients for booking a surgery or charging no-shows on the day of
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surgery is common in the USA; however, it would be challenging in public health systems
(2).
Sometimes a patient comes to the hospital without fasting or is late to the preoperative
preparation. Providing written instructions for preoperative preparation and reminding the

patients by phone, e-mail, or SMS can often resolve this problem (15). The financial more
frequently occur in countries that fund health care out-of-pocket or where poverty is endemic.
For instance, Okeke et al. (54) declared most patient-related causes in a Nigerian hospital
were due to financial issues.
4.2.4 Other considerations
Two other perspectives can be drawn from this research; first, the relationship between
hospital size and cancellation rate, and second, cancellation rate and the country, using GDP
per capita of the hospital’s location. We consider each of these perspectives below.
There is a correlation between hospital size and cancellation rates; for example, Schuster et
al. (55) found that surgical cancellation rates in University hospitals and large community
hospitals were respectively 2.23 and 1.65 times higher than medium- and small-sized
community hospitals. However, our results show the opposite relationship. The correlation
between the number of scheduled surgeries per year (as a proxy for the hospital size) and the
rate of cancellation is -0.337, indicating lower cancellation rates at larger hospitals.
Our results are likely different from Schuster et al. (55) for two reasons. First, they used a
two-week survey of 25 German hospitals of different sizes and types. This short period does
not capture annual fluctuations, and the results may look different with an extended period of
study. Second, the data are from a single country with all hospitals affected by the health
system policies.
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Regarding the correlation between cancellation rate and country, we observe a big difference
in the cause of unavailability of OR time between Finland and North India (16,44),
suggesting a relationship between cancellations and national resources. Hospitals in more
developed nations likely have access to more resources that can be used to schedule
effectively and drive down cancellation rates. Thus, we focused on parameters that can affect

the cancellation rates, such as GDP per capita for the country, hospital type, and the research
year. The regression and p-value showed that there is a significant relationship between the
GDP per capita and the rate of surgery cancellation, while there is not a significant
relationship between the year of research and the hospital types. The correlation between the
rate of cancellation and the GDP per capita is -0.251 (see Figure 3), suggesting countries with
higher GDP have lower cancellation rates. Wealthy nations can invest in health systems to
support planning and capacity management.
4.3 Strengths and Limitations
This SR excluded studies not published in English; therefore, studies published in other
languages might be overlooked. The research considered only cancellations reasons,
neglecting the investigation of solutions. We did not search the grey literature.
4.4 Implications for policy, practice, and research
A major effort from the hospitals and public health bodies is required to improve the
recognized weakness of surgery cancellations. The systematic review outcomes provide
insights on how elective surgery cancellation rates can be decreased, which is a crucial
quality measurement. As many cancellations are avoidable and their causes can be controlled
by hospitals, effective hospital and resource management can provide improved productivity
and health care services.
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4.5 Conclusions
One of the critical challenges for healthcare systems has been elective surgery cancellations
as they lead to patient dissatisfaction, wasted resources, and higher health care delivery costs.
This review analyses surgery cancellations in different hospital settings and indicates

hospital-related causes are the main reasons for cancellation, followed by work-up and
patient-related causes.
The reported hospital-related causes appear to emanate from issues of OR scheduling and
resourcing, and as such we believe these causes can be addressed by improved
organizational, rather than clinical, management. The OR can be effectively utilized and
scheduled to reduce cancellations by reasonable estimation of uncertainties in duration and
demand such as surgery duration, transportation, preparation, cleaning time, and emergency
arrivals. Furthermore, cooperation and communication between the various departments
involved in the surgical process can reduce surgical cancellations (15).
However, without proper hospital and resource management and planning, spending
money on new hospital equipment and resources is not an effective solution. Traditionally,
the most common approach is to request additional capacity—add more beds when beds are
running low (46)—however, there are limits on using this approach due to shortages of
capacity and budget restrictions. Furthermore, adding further capacity is not an immediate
solution and only addresses the symptom (lack of capacity) rather than the root cause (poor
capacity management) of the problem. Such an approach is short-sighted and largely
ineffective in the long term (46).
Authors’ contribution
Mona Koushan: Designed the study, acquired data, undertook the quality assessment of
studies and the statistical analysis, interpretation, and drafted manuscript.
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Lincoln C. Wood: Supervised, designed the study, undertook the quality assessment of
studies, check the statistical analysis, and revised the manuscript.
Richard Greatbanks: Supervised, designed the study and revised the manuscript.
Ethics approval

Not applicable.
Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Conflict of interest
The authors have disclosed that they have no significant relationship with, or financial
interest in, any commercial companies pertaining to this article.
Acknowledgment
None.
Data sharing statement
All data generated or analyzed during this study are included in this article and the data that
support the findings of this study are available from the corresponding author.
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18
Table 1 Keywords and search terms for each database. The differences in search terms
reflect the different search options available in each database
Database Search term
Web Of Science (WOF) (TS=(( postpon* OR cancel* ) AND ( surg* OR operat* OR
case* ) AND ( caus* OR reason* )))
EMBASE ((postpon* or cancel*) and (surg* or operat* or case*) and
(caus* or reason*)).af.
Medline (postpon* OR cancel* ) AND (surg* OR operat* OR case*
) AND (caus* OR reason* )
Table 2 Ranking of surgery cancellation reasons in various hospitals based on reviewed

studies in different categories (hospital-related causes (HR), patient-related Causes (PR),
work-up related causes (WR).
Reason Average* Rank

No OR time (HR) 13% 1
Change in medical status (WR) 11.6% 2
Medical unfit (WR) 11.2% 3
Administrative (HR) 8.3% 4
Absent of patient (PR) 7.1% 5
Lack of bed (HR) 7% 6
19
Change in the treatment plan (WR) 6.9% 7
Patient refuse (PR) 6.5% 8
Financial problem (PR) 5.9% 9

List transfer (HR) 5.2% 10
Equipment failure (HR) 4.7% 11
Anesthesia work-up(WR) 4.3% 12
Unavailable surgery staff (HR) 4.1% 13

Patient not following preoperative instruction (PR) 2.5% 14
Staff neglect (HR) 1.7% 15
 The average column is normalized by ignoring the unknown reasons.
Figures:
20
Figure 1 PRISMA flow chart-Systematic research and study selection for SLR of causes of
cancellation
21
25000
Number of scheduled surgery per year (Hospital

20000
15000
size)

10000
5000
y = -16360x + 7083.6
0
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Surgery cancellation rate
Figure 2 Correlation between the numbers of scheduled elective surgery per year (hospital
size) and the rate of cancellation. Larger hospitals that conduct more surgeries achieve lower
cancellation rates.
120000
100000
80000
GDP per capita
60000
40000
y = -75016x + 40009
20000
0
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
Rate of surgery cancellation
Figure 3 Correlation between the Gross Domestic Product (GDP) per capita and the rate
of cancellation. Larger hospitals that conduct more surgeries achieve lower cancellation
rates.
22

Factors Associated With Cancellation and Delay of Elective Surgery

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Factors Associated With Cancellation and Delay of Elective Surgery

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Evaluating Factors Associated with the Cancellation and Delay of

Elective Surgical Procedures: A Systematic Review

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Lincoln C. Wood, Ph.D., Associate Professor, Department of Management, Otago Business

Richard Greatbanks, Ph.D., Associate Professor, Department of Management, Otago

Corresponding Author: Mona Koushan. Department of Management, Otago Business

Header: Surgery Cancellation: An SR.

© Crown copyright 2021.

Background: Elective surgery cancellation is considered a fundamental problem in health

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resources and create a more predicable patient flow.

Methods: A systematic review was performed on elective surgery cancellation in compliance

Systematic Reviews (AMSTAR) guidelines.

patient-related causes (e.g., absence of a patient, patient refusal).

Key Words. Quality improvement, Operation room underutilization, surgery cancellation.

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patients and families as their daily life is disrupted (5,6).

discuss patients' medical status, surgeon-related causes, and anaesthesiologist-related causes

different hospitals and countries.

2.1 Search Strategy

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Web of Science, EMBASE through Ovid, and Medline through ProQuest.

2.2 Review Process

list of citations (n=78).

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the medical methods of the surgery.

2.4 Data Extraction

included in the SR (see Figure 1- PRISMA flow chart).

number of canceled surgeries, rate of cancellation, and percentages of different causes of

cancellation. A description of the data is presented in the appendices.

2.5 Quality assessment

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description of method or results (5,11,13).

2.6 Risk of Bias within and across studies

reasons: 51 retrospective studies (e.g., (6,14,15,16–24)) and 19 prospective studies (e.g.,

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and solutions to surgical cancellation in the last decade.

many different causes and contexts—i.e. a multi-factor problem—are likely involved.

detail in section 4.2.5.

causes, applicable solutions, and policies to overcome these problems.

4.1 Statement of principal findings

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related causes also have a considerable effect on elective surgery cancellation.

4.2 Interpretation within the body of literature

4.2.1 Hospital-related causes

and staff neglect.

canceled due to unavailability of OR time because of general anesthetic restrictions (44);

however, it was only 0.6% of in Hyvinkää Hospital in Finland (16). Underestimating of

surgery duration by surgeons (26).

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related to administrative problems. Due to the lack of resources dedicated to emergency

Scheduling problems leading to cancellations are commonly caused by delays from a

electronic scheduling implementation at a Veterans Affairs Medical Center (USA) showed a

emergency services by providing emergency surgery at a different site or by sending the

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4.2.2 Work-up related causes

4.2.3 Patient-related causes

preoperative telephone confirmation of patient attendance decreases non-attendance by 10%

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were due to financial issues.

4.2.4 Other considerations

rate of cancellation is -0.337, indicating lower cancellation rates at larger hospitals.

suggesting a relationship between cancellations and national resources. Hospitals in more