The most important finding in the present study was the high frequency of planned orthopaedic surgery cancellations. Of all patients who had a scheduled time for planned surgery 6,911 (39%) had their surgical procedure cancelled at least once and some several times. In Sweden, the large university hospitals tend to have the longest waiting times for orthopaedic procedures . Whatever the reasons for the long waiting lists, they lead to issues for the patients and organisational problems for the clinics, with overloaded surgical schedules and, at the end of the day, cancellations .
A delay in the planned surgery due to cancellation might contribute to the unnecessary “de-conditioning” of a pain-ridden patient and might also reduce the chances of achieving optimal results and/or prolong the postoperative rehabilitation process. The cancellation may also lead to a loss of confidence in the hospital, contributing to feelings of insecurity and uncertainty and thereby contributing to new cancellations. Last-minute cancellations have been shown to increase the patient’s fear and create a low level of trust in the hospital. It has also been shown that feelings of insecurity can lead to increased pain, leading to a prolonged hospital stay [14, 15].
The present study revealed a variety of reasons for the cancellations. When categorised, one third could be attributed to the most common reason, i.e. patient-related 3,293(33%) (Table 1). The cancellations which took place on the patient’s own request, in order to have the surgery performed on a later occasion or because the patients could not manage to wait and therefore chose other alternatives, provided 1,672 (17%). The categories comprising family reasons, work or other social reasons were the causes in 1,621 (16%) of the cancellations. It is probably possible to avoid most of these cancellations. The category comprising patients who refrained from surgery at the clinic, chose another hospital or abstained from surgery also includes those who, during the waiting period, improved to such an extent that they abstained from surgery (Table 1). A careful examination and an improved dialogue with a deeper understanding on both sides, i.e. the patient’s and the nurse’s or physician’s, are likely to eliminate many of the cancellations in this category. It has already been suggested that improved patient information and education, as well as the more careful establishment of the indications for surgery, “might reduce the circumstances when surgery is no longer necessary” [19–22].
It is likely that, when patients feel that they are more involved in their care and know what will happen next, fear and doubt, contributing to cancellations, can be reduced. In a Norwegian study, the focus was changed to a new pathway where the patients themselves selected the day and time of surgery . The hospital made a phone call to the patient two days before surgery to check that nothing was going to prevent the patients attending at the planned time. The hospital’s continuity resulted in a dialogue in which the patient could ask questions and the hospital could respond and support. This led to a high satisfaction rate for both parties and fewer cancellations compared with the group of patients that were treated according to the traditional pathway . It has also been shown that patients’ wishes to know where they are on the waiting list and how they are prioritised are important if the patients are to feel involved and have the opportunity to control their own situation, which leads to more trust in the hospital’s planning systems and care . Similar results have been reported when the concept of person-centred care (PCC) has been employed. In PCC, the patient is seen as an active partner involved in all decisions relating to the planning of his/her own care . The concept of the patients being integrated into healthcare may decrease disappointments or unrealistic outcomes related to misunderstandings or miscommunication  Studies of PCC have reported positive outcomes for patients with hip fractures, as well as patients with heart failure, resulting in more involved patients and also in shorter hospital stays [27, 28]. It has recently been found that the Swedish health-care system often fails to anticipate and respond to patients as individuals with particular needs, values and preferences .
Changing the view of the patient and including him/her in the whole planning process might be a way to reduce several of the reasons for cancellations, especially those directly related to the patient or to a poor pre-operative investigation .
In the present study cancellations related to incomplete preparations before surgery remained 1,181 (12%) (Table 1). Nurse-led pre-operative consulting has been shown to reduce the number of short-term cancellations, making the patients better informed, feeling safer and more motivated  the same findings as in the PCC concept. When the patients are well prepared before the operation, the cancellations for patient-related reasons decrease, resulting in fewer cancellations initiated by anaesthetists or surgeons on the day of planned surgery as well [19, 24, 31–34]. Pre-operative instructions not being followed or patients not being instructed adequately are issues that can be improved in order to reduce cancellations [19, 35, 36]. Having control of the situation and knowing what is going to happen next have also been shown to reduce the number of patients’ short-term cancellations .
In this study, 138 (2%) of the patients never showed up at the booked appointment for surgery. Sending a reminder text message a few days before the surgery to confirm the scheduled time has been shown to reduce the number of last-minute cancellations and also reduce the group of patients who do not show up at the appointed time [34, 37].
The second most common cause of cancellations was the treatment guarantee, enforced in order to minimise or eliminate waiting times longer than three months. When a planned surgical procedure cannot be performed within the stipulated three months, the hospital has the option of transferring the patient to other care-givers. If the guarantee cannot be upheld, the hospital misses out on government money allocated for this purpose. The frequent use of transferring patients underscores the discrepancies between the demands for orthopaedic surgery and the clinic’s inability to satisfy these demands within 90 days. Even if the guarantee means that the patient will have surgery at an earlier time, it is still a cancellation and the patient is withdrawn from the waiting list and forced to have surgery elsewhere. It is likely that every cancellation, irrespective of its cause, is a disturbance that can have a number of varying, mostly negative consequences for the patients and the clinic. Waiting times for surgery cannot be regarded simply as an isolated phenomenon, they must also be considered in the wider perspective of the entire health-care system, at least in a specific area or county .
The present study can also be interpreted as a report on the situation when both elective and emergency cases are mixed at the same surgical clinic. Most of the research related to cancellations and waiting lists has focused on the planning and scheduling of elective surgery, although a common reason for cancelling elective surgery is prioritised emergencies. This study showed that almost 869 (9%) of all cancellations were due to emergency cases with higher priority [8, 39, 40]. The almost doubled number of cancellations in 2010 (Table 1, #5) most probably due to an extreme winter with months of icy and snowy streets can serve as an example. An overloaded surgical schedule might be avoided using an operating room reserved for emergency cases only. A separate orthopaedic trauma operation room has resulted in measurable changes, such as more emergency surgery being performed during the day, instead of the evening and during the night. It has also resulted in fewer complications due to a good fit with surgeons’ schedules and, as a result, less stress. The planned surgery was performed on time to a greater extent and cancellation rates dropped . A reduction in emergency cancellations was related to fewer conflicts between elective and emergency surgery when the planned patients had a new pathway that reduced the rates of cancellations of elective surgery .
Allocating a special person responsible for the constant update of the emergency list has been shown to prevent over-optimistic surgical schedules and to have a beneficial effect on reducing the number of cancellations . Having a visible whiteboard in the surgical clinic listing the acute patients waiting for surgery makes the staff aware and able to improve the scheduling and reduce cancellations . In the United Kingdom, there are national guidelines recommending that hospitals with acute orthopaedic surgery should have a separate waiting list for trauma surgery which should be updated every day by a person in charge of the operating clinic. The separate waiting list helps the acute patients to undergo surgery on time, reduces the waiting stage and leads to a reduced number of cancellations .
Planning ahead in multi-professional teams in terms of available personnel resources, ward space limitations and necessary equipment has also been suggested to avoid several cancellations . In this study, almost 336 (3.5%) were due to a lack of personnel, ward space or missing equipment.
It is obvious that some cancellations are unavoidable, such as when patients die, or the appearance of a new disorder that makes surgery at the planned time point inappropriate, an outbreak of contagion and so on. In the same way, it is obvious that the vast majority of cancellations can be prevented by improvements to the organisation .
Limitations of the study
Since there is both a continuous inflow and outflow from the waiting list, the numbers given can vary. This makes it difficult to provide the precise numbers from one moment to another.
Another limitation could be that different staff categories entered the data into the surgical planning system. They might have had different views of using terms and knowledge when handling the computer-based system. This in turn could have led to inconsistent grouping and categorising of the reasons for cancellations.
This study showed the cancellations at one specific clinic only, making the reproducibility unproven.