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Journal of Indian Association of Pediatric Surgeons
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ORIGINAL ARTICLE
Year : 2023  |  Volume : 28  |  Issue : 3  |  Page : 223-226
 

Reasons behind patients defaulting from elective pediatric urology procedures at a tertiary private teaching hospital in South India


Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission25-Dec-2022
Date of Decision18-Jan-2023
Date of Acceptance26-Jan-2023
Date of Web Publication02-May-2023

Correspondence Address:
Ramesh Babu
Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_182_22

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   Abstract 


Aim: The aims of the study are to audit the default rate of the provisional date of elective surgery in pediatric urology private practice and to study the factors involved in the postponement of elective operation dates by patients.
Patients and Methods: The audit involved analysis of reasons behind patients defaulting from elective pediatric urology procedures between January 2019 and December 2019 at a tertiary private teaching hospital in South India. The details were obtained from the outpatient register kept for elective booking. The details of actual procedures performed were obtained from OT records. From the defaulters, the reasons for postponement were obtained through personal/telephonic interview.
Results: A total of 289 patients were given dates for elective procedures. Among this, 72 (24.9%) defaulted, leaving 217 patients who underwent elective surgery. Among those who underwent surgery, 90 (41%) were elective day case (DC) procedures, whereas 127 (59%) were inpatient (IP) procedures. The default rate was 26/116 (22.4%) for DC procedures, whereas 46/173 (26.6%) for IP procedures, with no significant difference between them (P = 0.64). Among the 72 defaulters, the reasons for cancellation were as follows: financial factors (FFs) 22 (30.6%), lack of family support 19 (26.4%), function/grievance in house 10 (13.9%), respiratory illness 14 (19.4%), and treatment at a different center 7 (9.7%). FF (insurance denial) was significantly higher (P = 0.001) in crucial IP procedures at 19/46 (41%) compared to DC procedures at 3/26 (12%). The various diagnoses denied insurance were UPJO (7), VUR (6), hypospadias (4), UDT (3), and PUV (2).
Conclusions: FFs were mainly responsible for parents postponing their children's elective pediatric urology procedures in India. Universal insurance coverage for congenital anomalies might help overcome this most important cause of cancellations.


Keywords: Cancellations, default rate, insurance, pediatric urology


How to cite this article:
Manjarie AR, Raj S, Babu R. Reasons behind patients defaulting from elective pediatric urology procedures at a tertiary private teaching hospital in South India. J Indian Assoc Pediatr Surg 2023;28:223-6

How to cite this URL:
Manjarie AR, Raj S, Babu R. Reasons behind patients defaulting from elective pediatric urology procedures at a tertiary private teaching hospital in South India. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Jun 8];28:223-6. Available from: https://www.jiaps.com/text.asp?2023/28/3/223/375525





   Introduction Top


Postponement of surgeries can have a negative impact on patient's health, operation theater (OT) resources, and quality of care. Day of surgery cancellations are widely used as an indicator for operative effectiveness. However, there is a lack of knowledge regarding and the various factors contributing to the noncompliance of patients to the assigned dates of elective surgery.[1] Such cancellation was more common among pediatric population when compared to adults.[2] Furthermore, several methods have been employed for the allocation of dates for elective surgeries, and their effectiveness has been studied.[3] However, the factors involved in the failure to be compliant with the assigned dates will have an impact on the effectiveness of these methods. These factors may be both patient related and hospital related. Understanding the cause of such postponement is essential to devise a solution for the same.[4] The study aims at analyzing the default rate of the provisional date of elective surgery and exploring factors influencing parents deferring their elective slot allotted to treat their children's pediatric urology problem.


   Patients and Methods Top


The study was conducted at the pediatric urology department in a private teaching institution in south India. The institute offers tertiary care service to patients in and around Chennai. Expenses toward the treatment of surgical procedures are paid by the parents either out of pocket or through their health insurance.

Patients who were given provisional date for elective surgery between January 2019 and December 2019 were analyzed. Emergency cases (torsion testis and genitourinary trauma) and urgent cases (tumors), who were admitted without a booking slot, were not considered in this study. The list of the patients and their detail were obtained from the outpatient register kept for elective booking. Patients were given a provisional date, in person, during their visit, after obtaining a complete diagnosis and anesthetic fitness. The dates were usually decided considering the availability of the consultants, working days of the OT and patient factors (school holidays/parents ability to take work-off). In a private hospital, the waiting list was not huge; also, patients were given date face to face with their initial concurrence, thus limiting hospital factors for defaulting. OT records were the source of information on the procedures that were eventually performed.

The outpatient register for elective booking and OT records were compared to obtain the list of defaulters. The defaulters were those patients who had not had surgery performed on the day allotted to them, according to the booking register. The patients who demanded telephonically later date were considered delays and not defaulters. These defaulters were categorized into elective day case (DC) procedures and inpatient (IP) procedures.

The contact details of the defaulters were obtained from electronic records. They were contacted for a telephonic interview to find out the reason for their noncompliance with the provisional date of surgery. The reason for cancellation was categorized as follows: financial factors (FFs; needed time to arrange funds for hospital expenses as insurance was rejected citing congenital anomaly), social factors (SF: lack of family support), cultural factors (function/grievance in the house), medical factors (febrile or upper respiratory illness), and other factors (opted for the treatment at a different center closer to their house).

Data entry was done using Microsoft Excel, and analysis was performed using SPSS version 23 (IBM corporation 233 South Wacker Drive, 11th Floor Chicago, Illinois 60606-6307 U.S.A). Data were expressed as numbers and percentages. The qualitative variables were analyzed using Fisher's exact test. A difference with P < 0.05 was considered statistically significant.


   Results Top


Between January 2019 and December 2019, 289 patients were given dates for elective pediatric urology procedures, according to the department outpatient booking register. Among them, 217 (75.1%) had their surgeries on the date allocated, as indicated by the OT records. The remaining 72 (24.9%) were defaulters.

Among the 289 patients who were booked for surgery, 116 patients were given a date for DC procedures and 26 (22.4%) defaulted. Similarly, 173 patients were given dates for IP procedures and 46 (26.6%) defaulted. There was no statistically significant difference (P = 0.64, Chi-square) in the default rate between DC and IP procedures [Table 1].
Table 1: Contingency table comparing default rate among day care and inpatient procedures

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The defaulters (n = 72) were contacted and were interviewed regarding the reason for not being compliant with the allotted dates. Among the defaulters, 42/72 (58.3%) returned for an alternate date for their elective procedure after a period of 2–3 months; the reason for defaulting was obtained by direct interview in this group. The remaining was interviewed telephonically to find out the reason for default. The following reasons were found for the cancellations: FFs (insurance denial and time delay to arrange funds) 22 (30.6%), lack of family support 19 (26.4%), function/grievance in house 10 (13.9%), febrile/respiratory illness 14 (19.4%), and treatment at a different center 7 (9.7%). [Table 2] summarizes the procedures among the defaulters and their reasons. While FFs accounted for 3/26 (12%) of DC defaulters, among IP patients, the FF (insurance denial) was significantly higher at 19/46 (41%) and played an important role in them postponing the crucial procedure (P = 0.001, Fisher's exact) [Figure 1]. The various diagnoses denied insurance were: UPJO (7), VUR (6), hypospadias (4), and PUV (2) among IP patients and UDT (3) among OP defaulters. Only 3/25 (12%) patients who had insurance were approved; they had corporate insurance for more than 2 years – an essential factor to cover congenital anomalies.
Table 2: Distribution of procedures among defaulters and their reasons for deferring elective surgery: Financial factors due to insurance denial, social factors, cultural factors, medical factors, and other factors

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Figure 1: Bars represent defaulters among DC and IP elective pediatric urology procedures. Black areas represent financial factors (insurance denial) which was significantly higher (P = 0.001) in crucial IP procedures at 19/46 (41%) compared to DC procedures at 3/26 (12%). The various diagnoses denied insurance were UPJO (7), VUR (6), hypospadias (4), and PUV (2) among IP procedure and UDT (3) among DC procedures. DC: Day-case, IP: Inpatient

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   Discussion Top


While some centers favor walk-in models where the patient is admitted straight after the diagnosis and surgery performed after a period of hospital stay ahead, slot booking system is popular worldwide to optimize time/resource allocation. Allocating a date for elective surgery reduces preoperative stay and thus nosocomial infections. In addition to reducing the overall cost, elective booking also aids to prepare the parents mentally, arrange leave from work, and also address the social needs such as arranging child care for the siblings.

In this study, we have analyzed the default rate among patients who got elective OT slots booked for various pediatric urology conditions and also analyzed the reasons behind their decision to defer surgery to a later date. Among the few studies that exist on compliance with the provisional date of elective surgery allotted to patients, one study indicated that defaulting was more prevalent in genitourinary surgeries.[5] They further analyzed this particular subgroup to find the reasons for such defaults.

Our study revealed that approximately one-fourth of patients who were allocated a date were noncompliant. The default rates were almost similar for both DC procedures and IP procedures. Financial constraints and lack of familial support were found to be the leading causes for noncompliance. When comparing DC and IP procedures, insurance denial was a main factor for patients postponing major congenital uropathy where a prompt treatment was crucial. SFs predominated DC defaulters and most of them got their minor procedures performed at a later date without much health risk.

Although 58.3% of the defaulters returned for an alternative date after 2–3 months, the nonadherence of patients to the allotted date can lead to the under-usage of OT resources as the date could have been allotted to other needy patients ready for surgery. The leading cause of default, the financial constraint, was particularly due to the denial of insurance citing congenital internal or external defects. A subgroup analysis revealed that, among those denied insurance, there were conditions such as UPJO, VUR, PUV, and hypospadias. These conditions are usually covered in the west, enabling those children to benefit from prompt surgical correction.

The default rate in our study was almost twice as high when compared to a similar study conducted in a public-funded hospital.[6] While in public-funded hospitals, SFs play a main role, in a private setup, the situation is different. In a country like India, where a large group of middle-class family seeks private health care, unforeseen hospital expenses can create a deep hole in the parent's pockets. The precious time lost by deferring surgery because of insurance denial could lead to loss of renal function, recurrent UTIs, and growth retardation. This emphasizes the need for better insurance coverage for pediatric surgeries.

There are several limitations of this study. These findings may not be applicable for government institutes or government insurance-funded trust hospitals; the outpatient records and the contact information of the patients were electronic. On the other hand, the register kept at the outpatient department for provisional dates was manually maintained, leaving room for human error. These might have had an impact on the final results. Since more than half of the patients returned for an alternate date, allocating two separate dates with a few weeks interval can help them in choosing a second date to cover an unforeseen social emergency. Nurse–patient preoperative call log is another innovative idea to reduce such cancellations.[7] Dreuning[8] suggested one-stop surgery as an innovative solution for inguinal herniotomy in children, where outpatient visits, preanesthetic consultation, and daycare procedures all were completed on the same day, limiting the turnaround time.

Similar studies could be conducted across various medical centers involving more surgical departments over a prolonged duration. This could help in shedding more light on the reasons and their relative impact. Although the study has its own limitations, the data on the reasons for nonadherence to the allocated dates of elective surgery can be used to formulate and test new ways of reducing such defaults, thus resulting in optimal usage of available OT resources and delivery of health-care services, especially to the pediatric population. This study also suggests that loss of renal function due to delayed treatment should be prevented by widening insurance cover for children.


   Conclusion Top


Financial and SFs are mainly responsible for parents postponing their children's elective pediatric urology procedures in India. While financial limitation is only one factor in patients defaulting from proposed dates, universal insurance coverage for congenital anomalies might help overcome this most important cause of cancellations. Allocation of a backup date and nurse–patient call log could be other considerations to address social causes of delay in the treatment.

IRB approval: 67/IEC/RB/2018.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yıldız Altun A, Özer AB, Turhan Aksoku B, Karatepe Ü, Kilinç M, Erhan ÖL, et al. Evaluation of the reasons for the cancellation of elective procedures at level 3 University hospital on the day of surgery. J Perianesth Nurs 2020;35:514-7.  Back to cited text no. 1
    
2.
Turunen E, Miettinen M, Setälä L, Vehviläinen-Julkunen K. Elective surgery cancellations during the time between scheduling and operation. J Perianesth Nurs 2019;34:97-107.  Back to cited text no. 2
    
3.
Sobolev BG, Sanchez V, Kuramoto L, Levy AR, Schechter M, Fitzgerald JM. Evaluation of booking systems for elective surgery using simulation experiments. Healthc Policy 2008;3:113-24.  Back to cited text no. 3
    
4.
Al Talalwah N, McIltrot KH. Cancellation of surgeries: Integrative review. J Perianesth Nurs 2019;34:86-96.  Back to cited text no. 4
    
5.
Garnier S, Maillet O, Cereda B, Ollivier M, Jeandel C, Broussous S, et al. Late surgical correction of hypospadias increases the risk of complications: A series of 501 consecutive patients. BJU Int 2017;119:942-7.  Back to cited text no. 5
    
6.
Anand S, Tomar S, Dhua AK, Agarwala S, Bhatnagar V. An audit of the provisional date of elective surgery allotted to pediatric surgery outpatients of a tertiary care, public-funded teaching hospital of North India. J Indian Assoc Pediatr Surg 2021;26:427-31.  Back to cited text no. 6
  [Full text]  
7.
Lee CM, Rodgers C, Oh AK, Muckler VC. Reducing surgery cancellations at a pediatric ambulatory surgery center. AORN J 2017;105:384-91.  Back to cited text no. 7
    
8.
Dreuning KM, Derikx JP, Ouali A, Janssen LM, Tulder MW, Twisk JW, et al. One-stop surgery: An innovation to limit hospital visits in children. Eur J Pediatr Surg 2022;32:435-42.  Back to cited text no. 8
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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    Abstract
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