Date of Award

January 2026

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Melanie Sion

Abstract

Background:Surgical case cancellation is a persistent challenge in hospitals worldwide and is particularly consequential in resource-constrained settings where transportation barriers, financial instability, and limited perioperative capacity shape patients’ access to care. In Malawi, where Kamuzu Central Hospital serves as a major tertiary referral center, same-day cancellation of scheduled operations has been historically common and is believed to contribute to delays in care, extended hospitalization, and increased social and economic strain for patients. While previous work has described cancellation rates and operational drivers, little is known about the lived experience of patients after discharge or the broader financial, functional, and familial consequences of surgical delays. Research Aims This thesis aimed to: (1) compare demographic and socioeconomic characteristics of patients whose surgical procedures were cancelled with those whose operations proceeded as scheduled; (2) assess financial burdens associated with hospitalization, particularly transportation-related costs and barriers; (3) evaluate functional outcomes following discharge, including the development of new disability, the need for assistance with daily activities, and the time required to return to normal health; (4) characterize reported family, work, property, and financial difficulties arising after hospitalization; and (5) assess the completeness and reliability of the medical records system at Kamuzu Central Hospital through systematic comparison of clinical charts and a prospectively maintained surgical database. Research Question The study asked whether experiencing one or more surgical case cancellations, even when surgery is ultimately completed during the same admission, is associated with measurable increases in financial burden, prolonged functional recovery, and elevated social and familial disruption for patients. Methods/Approach A mixed-methods design was used, including prospective observation of surgical schedules, retrospective chart review, and structured telephone interviews. Between June and July 2023, scheduled operations and cancellations were recorded across operating rooms at Kamuzu Central Hospital, and baseline questionnaires were administered to affected patients. Additionally, paper medical charts from a six-month surgical database were retrieved to verify demographic and clinical data. Patients discharged for at least six months were contacted by telephone and interviewed regarding financial costs, transportation challenges, functional recovery, and household or occupational complications following hospitalization. Statistical analyses included group comparisons and multivariable regression models adjusting for age, sex, and socioeconomic indicators. Results A total of 290 participants were included, of whom 170 experienced at least one cancellation and 120 did not. Baseline socioeconomic characteristics were similar across groups. Patients with cancellations incurred higher transportation expenses, reported more frequent transport-related barriers, and experienced longer delays in returning to their usual health and activity levels. Functional limitations were more common in the cancellation group, including new disability and increased need for assistance after discharge. Cancellation was associated with higher odds of reporting family difficulties, work disruptions, property problems, and financial strain. Regression analyses confirmed that case cancellation remained significantly associated with increased financial costs and prolonged recovery after adjusting for demographic and socioeconomic factors. The assessment of the medical records system revealed substantial inconsistency and incomplete documentation, with fewer than half of database entries matched to corresponding paper charts and frequent discrepancies in names, dates, and clinical details. Statement of scientific impact and relevance for communities of interest, including patients This work demonstrates that surgical case cancellation in a low-resource tertiary hospital exerts meaningful and enduring effects on patients’ financial stability, functional recovery, and household well-being, even when operations are ultimately completed. These findings underscore the importance of reducing avoidable delays, strengthening perioperative systems, and improving transportation access and patient support services. The documented gaps in medical record completeness highlight a critical need for improved health information infrastructure, which is essential for safe clinical care, accurate monitoring of surgical outcomes, and effective system strengthening. By centering patient experience and quantifying the social and economic consequences of cancellation, this thesis contributes evidence directly relevant to clinicians, hospital administrators, policymakers, and the Malawian patients whose care depends on a functional surgical system.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 07/14/2028

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