May 9, 2019

Most Late Surgical Cancellations in a Rhinology Practice Are Avoidable, Study Finds

Examining patterns in surgical cancellations at a tertiary rhinology and skull base practice

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Most late surgical cancellations in a rhinology and skull base surgery practice were found to be avoidable based on a recent analysis of 640 surgical cases. The study, led by rhinologist and Vice-Chair of Surgical Operations at Cleveland Clinic Raj Sindwani, MD, aimed to identify patterns in 24-hour surgical cancellations in an academic rhinology and skull base surgery practice by examining late cancellations for two rhinologists over two calendar years.

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“One third of all healthcare dollars in the US are spent on surgical care and one minute of operating room (OR) time has been estimated to cost between $20-$100, so late or same-day surgical cancellation can be very disruptive and costly,” says Dr. Sindwani. “The amazing finding of our study was that the majority of these cancellations are avoidable.”

The study’s lead author, Christopher R. Roxbury, MD, noted that previous research has estimated the rate of late cancellations to range from as low as 0.5% to as high as 40% across multiple specialties, but that this is the first study that looked into the factors associated with late cancellations in rhinology and skull base surgery practice. Dr. Roxbury is Assistant Professor of Surgery at Cleveland Clinic Lerner College of Medicine and staff in the Head & Neck Institute, Section of Rhinology, Sinus and Skull Base Surgery.

An unexpectedly high rate of avoidable cancellations

The study examined 640 surgical cases performed by two rhinologists in the Cleveland Clinic rhinology and skull base practice from January 2016 to December 2017 and found that 39 (6.1%) procedures were cancelled within 24 hours of surgery. Of the 39 cancelled procedures, 69.2% (27) were indicated due to underlying inflammatory pathology and 30.8% were indicated due to skull base pathology.

“Overall, we found that about 6% of all reviewed cases were cancelled within 24 hours of surgery,” says Dr. Roxbury. “For an inflammatory case this translates to a loss of approximately 2 hours of OR time, and for each skull base case an average of 4 hours of OR time is lost.”

Dr. Sindwani explains that avoidable cancellations were defined as those cancellations that took place within 24 hours of scheduled surgery time that could have been prevented by review of the medical record or communication by the hospital staff with the patient before surgery.

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An investigation into the reasons behind late cancellations found that most (71.4%; 25 of 35) were avoidable. Patients scheduled for inpatient and skull base surgeries had their procedures cancelled primarily for medical reasons, whereas patient-related and financial factors were common causes of cancellation among inflammatory or less-severe cases.

“The majority of late cancellations could have been prevented by making sure that all medical problems or comorbidities were addressed during the preoperative work up,” says Dr. Roxbury. “Preoperative work up is usually done by our impact team within 30 days of the surgery, and within that month, health changes may occur that have not been addressed.”

Late cancellations cause a ripple effect throughout the system

In addition to being a significant inconvenience to both patients and hospital staff, late or same-day surgical cancellations lead to the underutilization of OR time and resources, loss of productivity and revenue, and disruptions in access to care. Furthermore, the added time and effort associated with rescheduling a surgical procedure can be a source of distress for the patients and extra financial burden for the healthcare system.

“A cancellation that happens within 24 hours of scheduled surgery can be very disruptive, because there is not enough time to get another patient scheduled within that surgical block,” says Dr. Sindwani. “This results in the loss of a highly valued block of OR time and further exacerbates the issues associated with access to care. So, there’s a real ripple effect that propagates throughout the system, because late surgical cancellations indeed have a major impact on the organization, caregivers and patients.”

Exploring ways to prevent late cancellations

In order to address the reasons for potential cancellations in a timely manner, Cleveland Clinic Surgical Operations is now exploring strategies to increase communications, change the timing of preoperative evaluations and assist patients with transportation on the day of the surgery.

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“We are exploring ways to increase communications with our patients through online and text messaging, as well as via video,” says Dr. Sindwani. “We are also considering transportation partnerships with Uber Health or Lyft Business to help patients get to their surgeries in those cases where transportation is indeed an issue.”

As a follow-up to the current study and in the hope of gaining further insights into this important topic, Dr. Sindwani’s team is analyzing outpatient surgical cancellations that took place across the entire Cleveland Clinic healthcare system in 2017.

“We are now looking at what is going on at a system-wide level and in different settings,” he says. “We hope to have the preliminary data of this study available soon.”

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