Literature Review

Factors impacting same-day cancellation of outpatient pediatric magnetic resonance imaging under anesthesia

Reviewed by Daniel Tsze, MD and Joseph Cravero, MD

Hoffman AS, Matlow A, Shroff M, Cohen E.  Pediatr Radiol. 2015;45:99-107.

Abstract
Same-day cancellations for MRI studies to be performed under general anesthesia can have negative economic and emotional implications for families.  Only through a thorough understanding of these events can systems be designed to prevent future occurrences.  This study describes a single children’s hospital’s effort to study the nature and reasons for these cancellations.

This study was a retrospective case-control study of a single tertiary care children’s hospital that identified 111 outpatient anesthesia-supported MRI studies that were cancelled on the same day as the assessment.  A same-day cancellation was defined as a cancellation that occurred after the family arrived in the diagnostic imaging department and a minor assessment had been performed by a nurse, anesthetist, or radiologist, with a subsequent determination that the neuroimaging could not be performed satisfactorily.

When compared to matched controls in multivariate analysis, “living in the lowest income areas” was the only social factor associated with an increased risk of cancellation when compared to those living in the highest income group (OR 3.8, 95% CI 1.2, 12.3).  Overall, the most common factors given for cancellations were intercurrent illness (39.8%), patient not fasted (13.6%), and too unwell for anesthesia, unspecified (7.6%).  Of note, there was no difference in proportion of cancellations due to intercurrent illness between the different socioeconomic groups.

The only medical factor in multivariate analysis associated with cancellation was the number of medical services a patient was receiving (determined by counting the total number of consulting services seen at the hospital):  patients receiving more medical services experienced fewer cancellations (OR 0.78, 95% CI 0.62, 0.98).  Overall, the most common system factors for cancellations were necessary results unavailable (11.9%), inadequate sedation (3.4%), and other/not stated (3.4%).

Commentary

Given the significant cost resulting from cancelled MRI studies requiring anesthesia support, identifying both risk factors and modifiable items would be an important step towards ameliorating said problem.  When examining social factors related to cancellations, the authors did not explicitly examine the mechanism by which lower socioeconomic status increased the risk of same-day cancellations.  Although this social factor is not readily modifiable, it is possible that other factors known to be associated with lower socioeconomic status (e.g. poor health literacy)1 could be addressed by implementing strategies such as plain language communication principles; providing different forms of information; and improving opportunities for families to ask questions and receive clarification.2

When identifying potential medical risk factors and modifiable items related to cancellations, the number of medical services a patient was receiving reflected patient complexity, although other metrics used to reflect patient complexity did not appear to be associated with the likelihood of cancellation.  In addition, these metrics of patient complexity did not differ between the cases and controls, which further impacted the authors’ ability to find a relationship between patient complexity and cancellations.  The authors identifed medical factors that appeared to be potentially modifiable (e.g. necessary results unavailable), but these reasons may be hospital-specific and not generalizable to other institutions.  

Ultimately, the reasons for cancellations may vary from institution to institution, but this study does offer insight into specific types. Social and medical factors could potentially be applicable to the populations served by other providers.  Every institution that faces similar challenges would be encouraged to carry out a similar analysis, with the results described by the authors serving as a basis for identifying likely factors associated with cancellations of same-day MRI studies requiring anesthesia support.

  1. Yin HS et al. The health literacy of parents in the United States. Pediatrics. 2009;124:S289-S298.

  2. Abrams MA et al. Health literacy and children: recommendations for action. Pediatrics. 2009;124:S327-S331.

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