Introduction: Our institution is a stand-alone elective orthopaedic unit. The majority of prospective arthroplasty patients undergo in-patient pre-operative assessment.

Aim: We assessed the efficacy of a consultant physician delivered pre-operative assessment clinic for patients undergoing elective hip arthroplasty in terms of financial costs, duration of stay, cancellation rate and postoperative complications.

Patients and Methods: A study was undertaken over a six-month period comparing two age and sex matched patient cohorts. Group 1 consisted of 40 patients who were admitted directly for hip arthroplasty, while Group 2 patients were admitted for in-patient assessment prior to being readmitted for surgery. Data collected included patient age, presence of comorbidities. ASA score and the presence of post-operative complications.

Results: Group 1 comprised 40 patients with a mean age of 62.7 years (51–70), while Group 2 included 50 patients whose mean age was 63.78 years (51 – 70). A majority of patients in both groups were male. A significantly lower number of comorbid conditions and a lower ASA score were noted in group 1 patients, when compared with group 2. In addition, a shorter duration of hospital stay was noted in Group 1 patients with an associated decrease in costs.

Only one patient (2.5%) from Group 1 was cancelled pre-operatively; this for treatment of a chronic comorbidity. Five patients (10%) in Group 2 were cancelled on admission for surgery. Four of these patients were cancelled for acute illness that had developed following in-patient assessment, with one being discharged for treatment of a chronic illness.

Discussion: In-patient assessment prior to joint replacement placed a considerable burden on patients and healthcare resources. Patients referred to the assessment clinic were sicker, had a longer duration of hospital stay and had a higher incidence of cancellations than their peers in Group 1. It is important to note that the majority of all cancellations were due to the presence of acute medical problems not present at the time of assessment. Thus we feel that the current practice of in-patient assessment is financially inefficient and does not produce a notable decrease on pre-operative cancellations. In our opinion it is better replaced with an anaesthetic assessment on an out patient basis.

Background: The total cost of a joint arthroplasty is a matter of increasing interest to health economists. Patients who are admitted for elective procedures and subsequently cancelled incur significant additional costs and prevent admission of other patients.

Aim: We undertook a study to examine the incidence, causes and costs associated with pre-operative cancellation in an elective orthopaedic unit.

Patients and Methods: We reviewed all orthopaedic admissions over a twenty-month period, from March 2000 to June 2002. A total of 1,220 patients were admitted for arthroplasty. 62 patients (5.1%) were cancelled pre-operatively following admission. Detailed analysis of these cases was then undertaken, with details and costings of ancillary investigations obtained from relevant laboratory and radiology departments.

Results of Cancelled Patient Cohort: Mean patient age was 71.5 years (versus 75.3 yrs for non-cancellations) with a slight female preponderance. Almost three quarters of cancellations (72.5%, 45 patients) were avoidable, subsequently having their procedure at a later date. The remaining seventeen patients had chronic comorbidities and were judged permanently unfit for surgery following further work up. Of the 45 deferred patients, 16 patients were postponed to allow optimization of comorbid conditions. 19 patients had their surgery delayed for acute illnesses that had developed in the fortnight prior to admission. Infection was the commonest cause of cancellation in this group (n=18), with one patient cancelled due to a pre-operative DVT. The residual 10 patients were cancelled due to improvement of symptoms (4) unavailability of blood (3), anaesthetic equipment failure (2), and patient wishes (1). A comparison was performed using Student’s t test between patients temporarily deferred or permanently cancelled on the basis of age, comorbid conditions, ASA score and duration from in-patient assessment to admission. Only ASA scores demonstrated a significant difference between the two groups (Deferred 2.39, Cancelled 2.92; p< 0.01). The mean cost per admission was €10,187.26 with “Hotel” costs forming up to 75% of the total. While patients who were operated on inevitably incurred significantly higher costs (p< 0.01) it is noteworthy that the mean cost of admission per cancelled patient was €4,531, amounting to €77,010 over the study period. In addition, patient whose surgery was deferred incurred significant extra costs when compared with uncomplicated cases (mean excess €1,867). Therefore the additional costs of these 63 patients amounts to a total of €161,025.

Conclusion: Patients cancelled following admission incurred considerable costs. In order to minimize costs and maximize efficiency, we would recommend that the small cohort of patients with a high ASA score have a focused anaesthetic review pre-operatively. A program of education directed at patients and general practitioners would help eliminate minor illnesses, which necessitate cancellation, prior to admission.