Elective Surgical Case Cancellation and Reasons in Ethiopia: A Systematic Review and Meta-Analysis

Background: Cancellation of elective surgical operation recognized as a major cause of emotional trauma to patients as well as their families. In Ethiopia, prevalence and reasons for elective surgical case cancellation are variable from time to time in different settings. This systematic review and meta-analysis aimed to nd the pooled prevalence of elective surgical case cancellation. Besides, it aimed to nd reasons for elective surgical case cancellation in Ethiopia. Methods: The databases for the search were Web of Science, PubMed, and Google Scholar by the date 02/08/2020. To assess publication bias Egger's test regression analysis was applied. Results: This meta-analysis included a total of 5 studies with 5591 study participants. The pooled prevalence of elective surgical case cancellation was 21.41% (95% CI: 12.75 to 30.06%). Administration-related (34.50%) was the most common identied reason. Followed by Surgeon (25.29%), Medical (13.90%), and Patient-related reasons (13.34%). Conclusions: The national prevalence of elective surgical case cancellation was considerable. The most common reason for elective surgical case cancellation was administration-related reasons, followed by the surgeon, medical and patient-related reasons. The administrative or management-related reasons for the cancellations are potentially preventable. Thus, efforts should be made to prevent unnecessary cancellations through careful planning.


Background
Elective surgical case cancellation refers to a scheduled surgical procedure that not performed on a given day [1]. It have been a major and long-standing problem for healthcare organizations across the world [2]. Many patients on the elective surgery not operated upon the waiting list [3].
Most hospitals invest considerable resources in maintaining operating suites. But, unanticipated can cellation of scheduled surgery is of concern [4]. In developing countries, cancellation of elective surgical operation is a common phenomenon [5].
Day of surgery cancellation is a well-recognized re ects ine ciency in management [6]. It contributes to frustration and mental stress to the patients and their families [7]. It also increases the waiting period for the patients [8]. Besides, it surges the economic burden due to extended hospital stays [9,10]. Moreover, delayed surgeryincreases the risk of in-hospital death [11]. There are many reasons for the cancellation of elective surgical cases but they might differ from hospital to hospital [12]. Unexpected cancellations of planned surgery divided as avoidable and unavoidable cancellations [1]. Cancellations like scheduling errors, equipment shortages, and inadequate preoperative evaluation are avoidable cancellations. Unavoidable cancellations are emergency encounters and unexpected changes in the patient's medical status [13]. Different literature suggests that with improving the planning most cancellations are avoidable. It has also suggested that patients themselves should receive early notice of their operating day, and a reminder of their appointment [14].
In Ethiopia, different primary studies had conducted to determine the prevalence of elective surgical case cancellation and reasons. The prevalence of elective surgical case cancellation found in the range between 8.9% to 33.9% [24,25] in the Ethiopian setting. Hence, discrepancies between studies make it di cult to generalize the national problem. Having national representative data is real to underpin effective management strategies. Thus, a need to have a pooled estimation of elective surgical case cancellation recognizes at the country level. This systematic review and meta-analysis aimed to nd the pooled prevalence of elective surgical case cancellation. Besides, it aimed to nd reasons for elective surgical case cancellation in the Ethiopian setting. The review question was what are the prevalence and reasons for elective surgical case cancellation in Ethiopia?

Reporting
We reported the result of this meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline [26] (Additional le 1 research checklist).

Literature search
The databases for the search were Web of Science, PubMed, and Google Scholar databases. The terms for the search were pre-de ned for a comprehensive search strategy. These included all elds within records and Medical Subject Headings (MeSH terms). In the Boolean operator, within each axis, we combined keywords with the "OR" operator. Then we linked the search strategies for the two axes with the "AND" operator. The search terms used for the search were "surgical case cancellation" OR "elective surgical case cancellation" AND "prevalence" OR "magnitude" AND reasons of surgical case cancellation AND "Ethiopia". The speci c searching detail in PubMed with MeSH terms was ("magnitude of surgical case cancellation"

Study selection
All retrieved studies were exported to Endnote version 7 (Thomson Reuters, London) reference manager that we used to remove duplicated studies.
The retrieved articles were screened according to pre-de ned inclusion and exclusion criteria. Discussion and/or involvement of the third reviewer resolved any disagreements.

Inclusion criteria
Included studies were articles that reported the prevalence of elective surgical case cancellation and/or reasons for elective surgical case cancellation. Studies published in English and studies conducted only in Ethiopia. The publication year of the studies was not limited during the search.

Exclusion criteria
Excluded criteria were articles without full-text available and qualitative studies. Other excluded criteria were any reviews, commentaries, consultants' corners, letters, and conference abstracts.

Quality assessment
We used Joanna Brigg's Institute (JBI) quality appraisal criteria [27]. It is the assessment tool used to check the quality of each article. The tool consists of nine major items. The rst item is appropriate to the sample frame.
The second is the appropriate sampling technique. The third is the adequacy of the sample size. The fourth is a description of the study subjects and settings. The fth is enough coverage of data analysis. The sixth is the validity of the method for identi cation of the condition. The seventh item is a standard and reliable measurement for all participants. The eighth is the appropriateness of statistical analysis. And the last item is adequacy and management of response rate. Studies considered low-risk when it would t 5 or above quality assessment checklists.

Data extraction
Three authors extract the data. The following information extracted from the each article. Such as rst author, publication year, study design, study population, sample size, prevalence and reasons. The location of the study and the reasons for elective surgical case cancellation were also extracted.

Outcome measurement
This systematic review and meta-analysis have two major outcomes. The rst outcome is to determine the prevalence of elective surgical case cancellation in Ethiopia. It calculated as dividing the number of elective surgical patients but whom surgical cases canceled to the total number of patients multiply by 100. A total number of patients refer to elective surgical patients in the study period. The second outcome of the study was to identify the reasons for elective surgical case cancellation.

Data analysis
The required data were collected using a Microsoft Excel 2010 workbook form. It used to collect the rst author, publication year, study design, study population, sample size, prevalence and reasons. Then, the STATA Version11 software was used to analyze the data. The original articles presented using tables and forest plots.
Egger's regression test was also used to assess publication bias [30]. Furthermore, analysis were also carried out based on the reasons for elective surgical case cancellation.

Literature search result
A comprehensive literature search of the database yielded a total of 81 publications. Among these, 76 disregarded due to abstracts and titles. A total of ve eligible studies [24,25,[31][32][33] with 5591 study participants were identi ed for analysis of prevalence. Of these, three studies [24,25,33] with 3379 subjects identi ed for analysis of reasons (Figure 1).

Characteristics of included studies
The range of publication year for included studies was from 2015 to 2020. Two regions and Addis Ababa, the capital city of Ethiopia was the settings where studies found. Three studies in Addis Ababa [24,25,31], one in Oromia [32], one in Southern Nation, Nationalities, and People Region (SNNPR) [33]. All included studies were done by using the cross-sectional study design (Table1).

Quality assessment result
We assessed of studies with JBI quality appraisal checklists. Based on this, none of the included studies was poor quality status.

Meta-analysis
The absence of publication bias was assessed with Egger's regression test (p = 0.062), which showed that no publication bias.

Discussion
There is no acceptable case cancellation rate for e cient operating theatres. But rates under 5% are generally recommended [34]. According to this meta-analysis, the estimation of elective surgical case cancellation was 21.41% (12.75, 30.06) in Ethiopia. This is comparable with the study conducted in Sub-Saharan Africa [20] and Sudan [22]. Reasons for elective surgical case cancellation are almost similar in developing countries [20].
Besides, management strategies or surgical settings might be similar in developing countries, but lower than a study conducted in Nigeria [23], Uganda [35] and Malawi [21]. This discrepancy might be due to ndings of cancellation varying widely by study design; hospital type, country, and capacity; patient type (inpatients vs. outpatients). Evidence shows that surgical case cancellation rates vary because of a lack of a standard de nition, different patient populations and study methodology [36]. The current nding is higher than the study from Hong Kong China [16], Kingdom of Saudi Arabia [17], and Jordan [18]. This difference might be due to poor hospital administration strategies. Evidence shows that lack of materials, surgeons delay, the patient not fully prepared, preliminary examinations not carried out, a lack of beds in intensive care, inadequate administrative planning are indicators of poor hospital administration strategies [37]. This could cause the elective surgical case cancellation [10]. But not effective utilization of available resource hours, such as trained staff, appropriate facilities, equipment, good communication, operational layout [38].
Based on the estimation of the reason for elective surgical case cancellation, the most common identi ed reason was administration-related reasons. The same report from the Kingdom of Saudi Arabia [17], Jordan [18], Uganda [35], and Malawi [21] showed that administration-related reasons found the most common reasons of elective surgical case cancellation. This might be due to the reality is that surgical case cancellation can result in the nancially under-utilization of theatres [2]. So, during the surgical procedure, it could cause a shortage of surgical materials in the hospital setting and it makes in di cult to run the activities accordingly. This nding helps healthcare policy and/or decision-makers to consider elective surgical case cancellation prevention strategies.
Due to the lack of studies in some locations of Ethiopia, the result may not represent a national gure. Although I 2 is not an absolute measure of heterogeneity, high heterogeneity was observed.

Conclusions
In this nding, the prevalence of elective surgical case cancellation was considerable. The most common reason for elective surgical case cancellation was administration-related reasons, followed by surgeon-related, medical-related, and patient-related reasons. The reasons for the cancellations are potentially preventable and the vast majority of them are administration-related. Thus, efforts should be made to prevent unnecessary cancellations through careful planning. It means quality improvement strategies are necessary for surgical specialties that are susceptible to procedure cancellations caused by administrative reasons. Availability of data and materials: No need for more data. All information stated in the manuscript and, its supplementary information les.

Competing interests:
The author declares that, no competing interests Funding: There is no fund received from any fund agency.    Forest plot of prevalence with corresponding 95% CIs of the ve studies on elective surgical case cancellation.
The midpoint and the length of each segment indicated prevalence and a 95% CI. The diamond shape showed the combined prevalence of all studies.