In the current era of high healthcare spending, physicians must develop a heightened sense of financial awareness. Hospital systems, in response to external pressures, are constantly reevaluating their resource utilization and seeking ways to improve efficiency. In particular, the surgical setting is one area in which it is especially important to monitor costs and expenditures because wasted time can add up to thousands of wasted dollars.

At our institution’s outpatient surgery facility, patients often cancel or reschedule their surgical appointments. This can be managed and schedules can be adjusted accordingly when proper notification is received. However, a significant waste of resources occurs when patients do not show up for their scheduled procedure without any notification to the facility, surgeon, or office staff. These “no-show” patients can greatly disrupt the workflow and efficiency of any system.

Other authors looking at issues of operating room (OR) scheduling and resource allocation have identified several factors that contribute to OR cancellations, including the following:

• scheduling errors
• equipment problems
• cancellation due to a patient’s medical status
• emergency surgeries taking the place of scheduled surgeries
• “no-shows”

Predictors of patient “no-shows” for surgery include prior missed medical appointments, a history of alcoholism or other substance abuse, and a history of psychiatric issues or central nervous system impairment. As a result, it has been suggested that patients with a high risk of noncompliance be scheduled at the end of the day to avoid OR delays.

The cost of no-shows
When a patient is scheduled for surgery, there are many fixed costs including OR staff, anesthesiologist time, surgeon time, and equipment and medication that have been ordered in preparation for the procedure. If the patient is a no-show, these costs generally cannot be recovered and end up as losses to the hospital. Although the variability on a case-by-case basis makes it difficult to precisely quantify the dollar amount of these losses, previous studies have cited a ballpark cost of OR time—excluding physician fees—of $15 to $20 per minute.

In the current healthcare environment, minimizing wasted costs and expenditures is important to maintaining a functioning system. Physicians must be aware of sources of wasted costs and make their best efforts to minimize waste while still providing the best patient care possible. In the surgical setting, maximizing efficiency must include minimizing the number of cancellations.

We conducted a retrospective analysis of all scheduled surgeries at our institution’s outpatient surgery center over an 8-year period (from November 2004 to August 2012), focusing on canceled cases with the reason of “did not show up for surgical appointment.” We stratified these data by demographics, including insurance status (Table 1), and performed a chi-square test analysis.

Of nearly 24,000 procedures, 52 outpatient surgeries were canceled due to “no-shows.” Among all patients scheduled for surgery, most (93.1 percent) were covered by private payers. This was in stark contrast to the breakdown of the “no-show” group (57.7 percent private payer patients (Fig. 1).

Access to care
Access to care is an important issue, especially for patients with a low socioeconomic status. Regardless of healthcare economics and issues of efficiency, it is important for physicians to provide care to those in need. However, in the current healthcare climate, physicians have limited flexibility to provide care to those who are unable to pay. When hospitals and physicians are able to set aside time to care for those who lack the resources to pay for healthcare, this time must be used to the fullest extent possible.

To maximize the benefit of the free and subsidized care that physicians are able to provide, we recommend that healthcare providers recognize this issue of “no-shows” for surgery and take necessary measures to ensure that patients understand when and where to arrive for surgery and have the resources to get to the surgical facility.

For example, lower-income patients who take public transportation should not be scheduled for surgery too early or too late in the day, when such transportation is unavailable. In addition, medical staff should confirm that patients whose medical problem (such as an orthopaedic injury requiring immobilization) precludes them from taking public transportation have an alternative way to get to the hospital on time.

A survey of outpatient clinic patients in a predominantly low-income population has found that negative emotions and fear of uncomfortable procedures are the most common reasons patients cite for not keeping a doctor’s appointment. In a surgical setting, this fear is likely intensified and should be addressed by reassuring patients of the importance of the scheduled surgery and emphasizing that the benefits outweigh the risks of the procedure.

Finally, whenever practical, patients who receive free care and may be at increased risk of not showing up for surgery should be scheduled later in the day to avoid preventable OR delays.

Disclosure information: None of the authors reports any conflicts of interest.

Cynthia Kahlenberg, BA, is a medical student at the Northwestern University Feinberg School of Medicine; Robert J. Wetzel, MD, is a PGY-5 chief resident at the Northwestern University Feinberg School of Medicine Department of Orthopaedic Surgery; Sara L. Edwards, MD, is in private practice with SOAR medical group in San Francisco.

Bottom Line

• Today’s healthcare environment requires that physicians minimize wasted time and resources.
• This study of “no-show” patients for surgery found that a disproportionate number of patients who did not show were covered by some form of public aid.
• Patients who do not show for surgery frequently cite negative emotions and fear as their reason.
• To minimize the costs associated with no-show surgeries, hospitals should address patient fears, ensure that patients understand where and when they should arrive and have the resources to get there, and schedule those patients at high risk of not showing for surgery later in the day.

References:

1. Basson MD, Butler TW, Verma H: Predicting patient nonappearance for surgery as a scheduling strategy to optimize operating room utilization in a veterans' administration hospital. Anesthesiology 2006;104(4):826-834.
2. Macario A: What does one minute of operating room time cost? J Clin Anesth 2010;22(4):233-236.
3. Lacy NL, Paulman A, Reuter MD, Lovejoy B: Why we don't come: Patient perceptions on no-shows. Ann Fam Med 2004;2(6):541-545.