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How much are hospitals loosing due to inadequate navigation and cancellations?

Lengthy waiting lists for elective surgery are a daily struggle for patients and a headache for hospital managers. In this article, we be exploring the main causes and consequences of this reality in worldwide healthcare systems.

Matilde Ferreira

Matilde Ferreira

January 16, 2023 · 10 min read

operating room
Lengthy waiting lists for elective surgery are a daily struggle for patients and a headache for hospital managers. On one hand, they postpone the expected benefits of treatment, while pain and disability remain; on the other hand, delaying the procedures can have a significant impact on a facility’s financial security. In this article, we’ll be exploring the main causes and consequences of this reality in worldwide healthcare systems.
Before going further, there are some facts that we kindly ask you to keep in mind:
  • Surgery cancellation is the leading cause of operating room inefficiencies.1
  • Surgery cancellation cost up to €450 million annually.2
  • 80% of surgery cancellations are preventable.3
If nothing changes, those figures will keep spreading in the upcoming times with some major details pressing ahead: an expected always growing demand contrasting with the health workers shortage are fostering the perfect storm for healthcare systems.
Well, that’s why recruitment and retention efforts are key - but insufficient – drivers to handle such a complex challenge. New productivity enhancing and patient engagement strategies, linked with optimized processes will differentiate those providers able to increase capacity from those who will keep their patients and staff held hostage of lengthy processes and waiting times.

An unprecedented backlog is leading the way…

Long waiting times for elective (non-urgent) surgery have been a longstanding issue, dating back well before the pandemic, but COVID-19 has had a drastic impact on surgical delays, as providers have been forced to prioritize emergency and critical care cases. This shift in resources has resulted in a significant backlog of non-emergency procedures, including surgeries.
A study published in the British Journal of Surgery makes it explicit: 28 million elective surgeries worldwide have been cancelled or postponed in 2020.4 In the same year, surgery waiting times increased by about two months on average.5

… and waiting times are turning the spotlights on hospitals (for bad reasons)

Anyone working in a healthcare facility knows that surgical waiting times are a “everyone’s reality”:
  • In Portugal, around 20% of patients on the Surgical Enrollment List have exceeded the “maximum guaranteed response time” (TMRG).6
  • In Spain, a total of more than 700 thousand patients are waiting in line for surgery, which is the highest level since 2003.7
  • In England, experts talk about an “hidden” waiting list with more than 3.3 million people.8
  • In Canada , patients have never waited so longer for medical treatment, with neurosurgery, plastic surgery, and orthopedic surgery being pointed as major trouble areas.9
And we could keep listing… It is not unique, but it is crucial to understand the leading causes of surgical waiting times and to implement innovative strategies to mitigate them as soon as possible.

Finding the root causes for lengthy waiting lists in surgery

The root causes of surgical waiting times can be attributed to a variety of factors. Most commonly, it is due to a lack of resources, such as insufficient staff and equipment, poor coordination between different hospital departments and administrative issues can also contribute to waiting times, as well as the sheer number of patients requiring care.
Starting with human resources. It’s well known that health systems are facing a severe shortage of workers due to two major reasons – retirement and turnover – and the second one has been aggravating with growing rates of healthcare workers burned-out. Guess what: perioperative professionals are included in this challenging scenario.
While a current global shortage of 199,000 surgeons and 87,000 anesthesiologists is already reported,10 USA statistics show that, at the present time, more than half of anesthesiologists are 55 years old or older.11 So a new wave of physician retirements is imminent.
At the same time, the world’s population aged 60 years and older is expected to total 2.1 billion in 2050,12 representing an additional risk factor for multiple chronic diseases. The global demand for cancer surgery is expected to increase from 9.1 million to 13.8 million procedures over the next 20 years, and the surgical workforce will need to increase 47%.10
Focusing exclusively this reasoning line, sounds obvious that human and technical resources availability are the number one bottleneck for surgical waiting times, but what about the surgeries that are supposed to happen, block hospital facilities and healthcare professionals’ agendas and are cancelled at the last minute?

Cancellations: the hidden face of surgery waiting times

 A substantial part of the literature on waiting times for scheduled surgery has focused, specifically, on patients that have been treated. These studies disregard cancellations – surgeries that were scheduled to happen but for some reason were cancelled.13

Let’s put it plain: cancellations cost up to €450 million per year…
Evidence reports highly variable elective day of surgery (DOS) cancellation rates from 5% in Finland14 or 6% in Spain,15 10% - 14% in UK2 and Portugal,17 to 45% in South Africa.18
It's easy to understand that if an operating room is expected to be working and it changes unexpectedly, there are heavy efficiency losses and waiting times will not reduce – quit the contrary. What is much more difficult to understand is why it happens due to preventable reasons.
…And around 80% of cancellations are preventable
Besides the lack of resources, such as staff or equipment issues previously mentioned as drivers for waiting times, the reasons why a surgery may be canceled include an unforeseen medical issue, such as a sudden infection or complication; the patient's condition not being suitable for the procedure; or the patient not being able to meet the pre-surgery requirements.
In this regard, recent prospective epidemiological study in NHS hospitals states that clinical reasons are responsible for 33% of historical cancellations and 28% of contemporaneous cancellations.2 This include cancellations due to poor preparation or unexpected deterioration in patient health.
Well, what this means in practice is that around 30% of cancellations happen due to clinical reasons that could beneficiate from more accurate risk-stratification and/or better coordination between different teams and/or care levels.
Once again, it’s not only about having more resources, but also about changing processes to improve the way things are done and make sure that those people are delivering their best.
Last, but not least, increased anxiety levels, often due to a lack of communication and information from the practice staff, are reported by 50% of patients,16 resulting in them postponing or canceling the surgery altogether. All in all, preoperative instructions not being followed, lack of OR availability due to administrative issues, or patients simply not showing up, make up 70%17 to 80%3 of surgery cancellations. And all of them are preventable reasons.
And so, we come to the third takeaway: patient engagement and navigation enablers’ strategies, able to reduce either doubts or wrong behaviors that threaten surgery’s viability, also have their say when it comes to reduce intra-operative cancellations, consequently reducing – or at least not rising – surgical waiting times.

Final takeaways:

  • Surgery cancellation is the leading cause of OR inefficiency, increasing the big struggle of elective surgery waiting times, but around 80% of cancellations are preventable.
  • The global demand for surgery is expected to keep raising and patients will keep waiting if nothing changes on pre-surgical processes.
  • A current global shortage of 199,000 surgeons and 87,000 anesthesiologists is already reported, but these professionals keep wasting 20% to 30% of their time in tasks that could be automated.
  • 1 out of 5 cancellations18 are due to no attendance reasons that could be preventable by applying patient engagement and navigation enablers’ strategies.
If you want to keep on top of efficiency tips to increase your OR capacity, read the next blog post. If you prefer to have a conversation about how to reduce cancellations and surgical waiting times, schedule a call with our team.


  1. Abate, S. M., Chekole, Y. A., Minaye, S. Y., & Basu, B. (2020). Global prevalence and reasons for case cancellation on the intended day of surgery: A systematic review and meta-analysis. International journal of surgery open, 26, 55–63.
  2. Gillies, M. A., Wijeysundera, D. N., & Harrison, E. M. (2018). Counting the cost of cancelled surgery: a system wide approach is needed. British journal of anaesthesia, 121(4), 691–694.
  3. Koh, W. X., Phelan, R., Hopman, W. M., & Engen, D. (2021). Cancellation of elective surgery: rates, reasons and effect on patient satisfaction. Canadian journal of surgery. Journal canadien de chirurgie, 64(2), E155–E161.
  4. 28 million elective surgeries may be cancelled worldwide: How non-covid-19 medical care is suffering. (n.d.). Retrieved January 13, 2023, from
  5. State of Health in the EU: Companion Report 2021. (n.d.). Retrieved January 13, 2023, from
  6. Hospitais: As 25 listas de espera de cirurgias mais atrasadas do país. (n.d.). Retrieved January 13, 2023, from
  7. Güell, O. (2022, May 02). España Bate El Récord de Pacientes de la Sanidad Pública en espera para operarse por la Resaca de la Pandemia. Retrieved January 13, 2023, from
  8. University of Birmingham. (2022, June 28). NHS elective procedure waiting lists in England set to triple. Retrieved January 13, 2023, from
  9. Waiting your turn: Wait times for health care in Canada, 2021 report. (2021, December 15). Retrieved January 13, 2023, from
  10. Perera, S. K., Jacob, S., Sullivan, R., & Barton, M. (2021). Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis. The Lancet. Oncology, 22(2), 173–181.
  11. Anesthesiology: Supply, demand and recruiting trends - Merritt Hawkins. (n.d.). Retrieved January 13, 2023, from
  12. Ageing and health. (n.d.). Retrieved January 13, 2023, from
  13. Cima, J., Almeida, Á. The impact of cancellations in waiting times analysis: evidence from scheduled surgeries in the Portuguese NHS. Eur J Health Econ 23, 95–104 (2022).
  14. Turunen, Elina & Miettinen, Merja & Setälä, Leena & Vehviläinen-Julkunen, Katri. (2018). Financial cost of elective day of surgery cancellations. Journal of Hospital Administration. 7. 30. 10.5430/jha.v7n6p30.
  15. González-Arévalo, A & Gómez-Arnau, Juan & delaCruz, F & Marzal, Jose & Ramírez, S & Corral, E & garcia del valle, Santiago. (2009). Causes for cancellation of elective surgical procedures in a Spanish general hospital. Anaesthesia. 64. 487-93. 10.1111/j.1365-2044.2008.05852.x
  16. Mekonen, Semagn & Ali, Yigrem & Basu, Bivash. (2020). Global Prevalence and determinants of preoperative anxiety among surgical patients: A systematic review and Meta-analysis. 10.1016/j.ijso.2020.05.010.
  17. Kaddoum, R., Fadlallah, R., Hitti, E. et al. Causes of cancellations on the day of surgery at a Tertiary Teaching Hospital. BMC Health Serv Res 16, 259 (2016).
  18. Kumar, R., & Gandhi, R. (2012). Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital. Journal of anaesthesiology, clinical pharmacology, 28(1), 66–69.
Matilde Ferreira

Matilde Ferreira

Content Strategy & Communication Manager

Graduated in Communication Sciences, early on fell in love with storytelling. Started off as a journalist and then pivoted to the public relations world, she was always driven to craft relevant stories and bring them to the stage.

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