Researchers at Tulane University Medical Center found that in 2009, 327 of 4,876 (6.7%) scheduled elective outpatient surgeries were cancelled, costing the hospital nearly $1 million that year alone. Because surgeries bring in approximately 60% of the hospital’s entire revenue, that loss has a major effect on the bottom line, said study author Sabrina Bent, MD, MS, clinical associate professor of anesthesiology and director of research at the Tulane University Department of Anesthesia, in New Orleans.
“People need to recognize that there is a cost to cancelled surgeries that is not insignificant,” said Dr. Bent, who presented the findings at this year’s American Society of Anesthesiologists Conference on Practice Management (abstract PM23).
The bulk of the cost from cancelled surgery stems from “opportunity costs,” Dr. Bent said. When surgeries are cancelled on short notice, hospitals are unable to swap in other procedures that would bring in lost revenue.
Hospitals cancel surgeries at the last minute for various reasons, Dr. Bent noted. More than 30% of patients in her study failed to show up at the time of surgery because of transportation problems, confusion over the date of the procedure, forgetting about the appointment or for other reasons, she said.
Among the minority of cancellations besides no-shows for which the reason was recorded, nearly one-third of the procedures were cancelled because of issues at the hospital itself, such as a lack of beds or equipment. Although it is not in the hospital’s interest to cancel planned surgeries, these issues arise, Dr. Bent said. Scheduling errors can occur when one piece of expensive equipment is needed in two operating rooms at once, other equipment fails or the intensive care units happen to be full, leaving no place for patients to recover following procedures.
Dr. Bent and her team found that cancellations were more likely among patients who did not have a preoperative clinic visit with the anesthesiologist—nearly 11% of these surgeries were ultimately cancelled compared with less than 4% of surgeries preceded by a clinic visit.
As a result, Dr. Bent recommended that hospitals ensure all patients receive a preoperative visit to verify patients are medically ready for surgery and that they receive the proper preoperative instructions for the day of the procedure.
“That is a major factor that should be achievable,” she told Anesthesiology News. Other ways to reduce cancellations include improving the allocation of equipment and resources, and increasing efficiency to help patients move through the hospital faster, she added. “All of these things are multifactorial and take time, thus are hard to address easily.”
Consequently, Dr. Bent recommended that hospitals focus in areas where they could have the most impact. For instance, she and her team found that the cost of cancellation varies with specialty, with the highest loss in neurosurgery and urology (Table). Start with these high-revenue subspecialties, she said, and analyze and develop ways to curb those losses. “Maybe you cannot fix everything right away, but maybe there is something you can do to improve the efficiency and lack of cancellations in specialized groups.”
The rate of cancellations in the study “makes sense,” said David Glick, MD, MBA, associate professor of anesthesia and critical care at the University of Chicago, who conducts similar research. The total cost for Tulane probably exceeded $1 million, however, Dr. Glick said, because the hospital has a relatively small volume and cancelled surgeries also result in a loss of money when disposable equipment is opened and then must be thrown out.
“There can be significant losses to the medical centers when they lose cases because of cancellations,” Dr. Glick said. “I think their findings are useful, insofar as they provide justification for greater financial investment by hospitals to decrease cancellations.”
For instance, Dr. Glick’s own research also showed that patients who have preoperative visits in the anesthesia clinic are less likely to delay or cancel their surgeries (Anesthesiology 2005;103:855-859). Although these visits are largely not reimbursed, it may be in the hospital’s interest to support them financially. “I think this study suggests that it is reasonable for medical centers to bear a significant cost to maintain the anesthesia preoperative clinic,” Dr. Glick said. “It enables them to save more money down the line, when surgeries are not cancelled.”