key: cord-0802307-s4plqjt1 authors: Abate, Semagn Mekonnen; Chekole, Yigrem Ali; Minaye, Solomon Yimer; Basu, Bivash title: Global prevalence and reasons for case cancellation on the intended day of surgery: A systematic review and Meta-Analysis date: 2020-08-20 journal: International journal of surgery open DOI: 10.1016/j.ijso.2020.08.006 sha: fe79398acc8ad2e663232ec34249ac00466d8af1 doc_id: 802307 cord_uid: s4plqjt1 Abstract Background Cancellation of operation on the intended day of surgery affects the efficiency of Operation Room which incurs a significant financial loss for the patient, hospital, and health care cost of a country at large. This systematic and Meta-Analysis was intended to provide evidence on the global prevalence and determinants of case cancellation on the intended day of surgery. Methods Methods: A comprehensive search was conducted in PubMed/Medline; Science direct and LILACS from January 2010 to May 2020 without language restriction. The Heterogeneity among the included studies was checked with forest plot, χ2 test, I2 test, and the p-values. All observational studies reporting prevalence and determinants were included. Results A total of 1207 articles were identified from different databases with an initial search. Fort-eight articles were selected for evaluation after the successive screening. Thirty-three Articles with 306,635 participants were included. The Meta-Analysis revealed that the global prevalence of case cancellation on the intended day of surgery was 18% (95% CI: 16 to 20). The Meta-Analysis also showed that lack of operation theatre facility accounted for the major reason for cancellation followed by no attendant and change in medical condition. Conclusion The meta-analysis revealed that the prevalence of case cancellation was very high in low and middle-income countries and the majorities were avoidable which entails rigorous activities on operation theatre facilities, preoperative evaluation and preparation, patient and health care provider communications. Registration This Systematic Review and Meta-Analysis was registered in a research registry (researchregistry5746) available at https://www.researchregistry.com/browse-the-registry#home/ The same day case cancellation refers to any surgical case that is scheduled into the operation theatre list on the day before surgery but is not operated on as per the schedule (1, 2) . Operation Room (OR) is the financial centre of the Hospital (3-7) which can generate 40-50% of hospital and 60-70% of hospital revenue (8) with an average cost of 15 to 50 US Dollars per minute (3, (9) (10) (11) (12) (13) (14) . Cancellation of operation on the intended day of surgery affects the efficiency of OR, reduces utilization of OR time and waste resources which incur a significant financial loss for the patient hospital and health care cost of a country at large (2) (3) (4) (5) (6) (7) (9) (10) (11) (12) (13) (14) (15) (16) (17) . Cancellation of operation is the leading cause that decreases OR efficiency which has a huge impact on patient, staff, hospital, and health care delivery (2, 5, (9) (10) (11) (12) (14) (15) (16) (17) . The measure of OR efficiency is a controversial issue but studies reported that the surgical centre with a cancellation rate of less than 5% was considered efficient (2, 8, 18, 19) . The incidence of cancellation is very high which varied with the hospital setting, culture, and socioeconomic status of the nation. The cancellation rate in the developed country ranged from 2 to 40% (2, 9, 12, (20) (21) (22) while this rate is as high as 73% in low and middle-income countries (4, 7, 15, (22) (23) (24) (25) (26) . Studies reported that more than eighty Percent of cancellations were avoidable while only twenty Percent of cancellations were unavoidable (3, 10, 14-16, 19, 22, 27-33) . Studies figured out many reasons for cancellation of operation on the intended day of surgery which themed in two broader categories as patient-related factors such as a change in medical condition, no show-up, no attendance, refuse to give informed consent and facility-related factors such as lack of a bed, operation time, equipment, inadequate workup, staff unavailability, and others (2, 3, 5, 6, 10, 17, (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) . A cohort study done by Wong et al in the UK among 14 936 patients showed that 33.3% of patients were cancelled due to change in medical condition while 31% were cancelled because of insufficient bed capacity (18) . Another study conducted in the USA by Smith et al also showed that 51% of patients were cancelled because they were unfit for anaesthesia (20) . A study conducted in Meddle east by Morris et al among 760 patients found out that 67% of patients were cancelled due to patient-related factors (2) . A study from Brazil by Pinheiro et al revealed that 61.2% of patients were cancelled because of facility-related factors (45) . A prospective cross-sectional study conducted in Ethiopia by Desta et al showed that the majority of cases (35.8%) were cancelled because surgeons were not available (15) . A study done in Nigeria showed that 60.8% of cases were cancelled because they were not available (noshow) (46) . Body of evidence showed that patient cancellation on the intended day of surgery is associated with a significant psychosocial and economic impact on the patients and their families. Besides, it affects the health care delivery and revenue of the hospital which entails mitigating strategies to prevent avoidable surgical cancellations. Therefore, this systematic review and Meta-Analysis aimed to provide evidence on global prevalence and determinants of cancellation of cases on the intended day of surgery. J o u r n a l P r e -p r o o f The objective of this systematic review and Meta-Analysis was to investigate the global prevalence, determinants, and outcomes of cancellation of cases on the intended day of surgery. What is the global prevalence of case cancellation on the intended day of surgery? What is the prevalence of case cancellation on the intended day of surgery among the continents? What is the prevalence of case cancellation among Low and Middle-income countries What are the main reasons for case cancellation on the intended day of surgery? I don't think hypothesis testing is relevant in Meta-analysis just like the primary studies. The Primary purpose of systematic review and Meta-analysis is to provide high-quality evidence on predefined controversial issue/problem or inconsistent conclusion by randomized controlled trials or other observational studies by pooling their effect sizes. That is why hypothesis testing is not usually expected to be addressed in meta-analysis. J o u r n a l P r e -p r o o f The systematic review and meta-analysis were conducted based on the Preferred Reporting Items for Systematic and Meta-analysis (PRISMA) protocols (47) . This Systematic Review and Meta-Analysis was registered in a research registry (researchregistry5746) on June 24/2020 and available at https://www.researchregistry.com/browse-the-registry#home/ All observational (case series, cross-sectional, cohort, and case-control) studies reporting prevalence and determinants of cancellation at the intended day of surgery were included. Studies that didn't report the prevalence of cancellation on the intended day of surgery, studies conducted before 2010 were excluded. Besides, Randomized controlled trials, case-control studies, Systemic reviews, and Case reports were excluded. The primary outcome of interest was the prevalence of case cancellation on the intended day of surgery. Besides, the systematic review and Meta-Analysis identified the prevalence of the most common reasons for case cancellation on the intended day of surgery. The outcomes of case cancellation were not reported in the majority of included studies. However, systematic review and Meta-Analysis figured out the prevalence and determinants of outcomes of case cancellation on the intended day of surgery. The search strategy was intended to explore all available published and unpublished studies ) OR (reasons [Text Word]))))))))))))))) The data from each study were extracted with two independent authors with a customized format. The disagreements between the two independent authors were resolved by the other two authors. The extracted data included: Author names, country, date of publication, sample size, the number of cancellation, reasons for cancellation, types of surgery, and determinants. Finally, the data were then imported for analysis in R software version 3.6.1 and STATA 14. Articles identified for retrieval were assessed by two independent Authors for methodological quality before inclusion in the review using a standardized critical appraisal Tool adapted from the Joanna Briggs Institute (48) (Supplemental Table 1 ). The disagreements between the Authors appraising the articles were resolved through discussion with the other Two Authors. Articles with average scores greater than fifty percent were included for data extraction. Data analysis was carried out in R statistical software version 3. A total of 1207 articles were identified from different databases with an initial search. Fort-eight articles were selected for evaluation after the successive screening. Thirty-three Articles with 306,635 participants were included in the systematic review and Meta-Analysis while fourteen studies were excluded with reasons (2, 6, 16, 23, 30, 40, 43, 49-55) (Fig 1) . Thirty-three studies with more than one-third of a million participants conducted to investigate prevalence and reasons for case cancellation on the intended day of surgery were included ( Table 1) J o u r n a l P r e -p r o o f Thirty-three studies reporting prevalence and determinates of case cancellation on the intended day of surgery were incorporated in the Meta-Analysis. The Meta-Analysis was conducted with a random effect model as there was substantial heterogeneity between the included studies. The Meta-Analysis showed that the global prevalence of case cancellation on the intended day of surgery was 18% (95% CI: 16 to 20, 33 studies and 306,635 participants) The income levels of countries were categorized based on the recent World Bank classification of countries by their economic level. The subgroup analysis showed that cancellation was the highest among low-income and lower-middle-income countries: 40% (95% CI: 27 to 54, 6 studies and 5252 participants) and 23% (95% CI: 5 to 14, 6 studies, 1547 participants) respectively. The subgroup analysis revealed that the prevalence of cancellation was the highest in the African 4) . The Meta-Analysis also revealed that the prevalence of cancellation was the highest in Burkina Faso followed by Ethiopia, Uganda, Nigeria, Kenya and Brazil (supplemental This Meta-Analysis investigates the most common reasons from included studies to pool the independent risk factors of cancellation. The subgroup analysis revealed that lack of operation theatre facility accounted for the major cancellation, 23%( 95% confidence interval(CI): 20 to 25) followed by no attendant 19% (95% confidence interval(CI): 18 to 22) and change in medical condition(unfit) 17% (95% confidence interval(CI): 12 to 23) ( Fig 5) . The subgroup also showed that prevalence of cancellation was the highest among orthopaedic surgery 39% (95% confidence (CI): 38 to 40) and all general specialities 18 %( 95% confidence interval (CI): 16 to 20) (supplemental Fig 2) . Sensitivity analysis was conducted to identify the most influential studies with metainf command in R and the influence of individual studies on effect estimate didn't show a significant difference. Publication bias was investigated with funnel plot asymmetry and egger's regression, Begg's rank correlation test, and trim fill method. The trim fill showed that two large standard error studies were missed but the rank correlation test didn't show a significant difference (P-value < 0.1194) (Fig 6) . The Systematic review identified 28 J o u r n a l P r e -p r o o f The systematic review and meta-analysis incorporated sufficient studies with more than onethird of a million participants. The methodological quality of included studies was moderate to high quality as depicted with Joanna Briggs Institute assessment tool for meta-analysis of observational studies. However, substantial heterogeneity associated with differences in included studies in sample size, design, and location could affect the allover quality of evidence. The review included sufficient studies with a large number of participants but the majority of studies included in this review didn't report data on risk factors to investigate the independent predictors. Besides, there were a limited number of studies in some countries and surgical specialities which would be difficult to provide conclusive evidence with results pooled from fewer studies. Body of evidence revealed that the prevalence of cancellation was very high particularly in low and middle-income countries. The major reasons for cancellations were avoidable and mainly related to financial and human resources, low awareness, and inadequate preoperative assessment and preparations. Therefore, an extenuating strategy is required by different stakeholders to avoid unnecessary cancellations through performing adequate patient evaluation and preparation, creation of awareness towards anaesthesia, mobilization of resources to the operation theatre, separation of operation room suits for each speciality, and provision of incentives to operation theatre staffs and others. The meta-analysis revealed that the prevalence case cancellation on the intended day of surgery is very high and the major reasons for case cancellation were identified. However, the included studies were too heterogeneous, and cross-sectional studies also don't show a temporal relationship between the outcome and its determinants. Therefore, further observational and multicenter studies are in demand for specific types of surgical specialities. J o u r n a l P r e -p r o o f The meta-analysis revealed that the prevalence of case cancellation was very high particularly in low and middle-income countries. The majority of determinants of case cancellations were avoidable which entails rigorous activities on operation theatre facilities infrastructure, protocols on preoperative evaluation and preparation, patient and health care provider communications. Ethical clearance and approval were obtained from the ethical review board of the College of Health Science and Medicine. 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The authors declare that there are no competing interests No funding was obtained from any organization The Meta-Analysis revealed that the global prevalence of case cancelation was very highThe prevalence of case cancelation was the highest among low and middle-income countriesThe major reason for case cancelation was inadequate operation theatre facility Case cancelation was more prevalent among orthopedic surgical patients J o u r n a l P r e -p r o o f The following information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated. All authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. 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Trials and certain observational research can also be registered elsewhere such as: ClinicalTrials.gov or ISRCTN or numerous other registries.The systematic review and meta-analysis was registered in submitted for registration in Prospero and they are working on it a research registry (researchregistry5746) and available at https://www.researchregistry.com/browse-the-registry#home/ The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish Semagn Mekonnen Abate(AS) who is the corresponding author is the guarantor