Operation waitlist: barriers to life-saving surgeries
Even with the dazzling advancements in healthcare in the past 50 years, barriers to care seem to remain an unfortunate motif that stands in the way of improved collective health outcomes. Limited access to healthcare leads to suboptimal care for patients, which can carry serious consequences for some of the most acute cases—particularly those who require emergency surgical intervention. The conversation surrounding available resources and surgical outcomes is not a new one, and many of these disparities have been characterised over the years across various surgical subfields, from surgical oncology to paediatric neurosurgery. To make matters more complicated, the COVID-19 pandemic serves as an additional stressor and has compounded the strain on healthcare systems trying to meet the needs of their patient population.
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First, a number of pre-existing upstream elements can impede a patient’s ability to seek care. The social determinants of health are factors that include characteristics of a patient’s environment that may appear far removed from formal healthcare processes, but still significantly affect the patient’s health outcomes. For example, a patient’s limited access to nutritious food, clean water, education, and a safe living environment may predispose them to more serious conditions and complications in their surgical care than if they enjoyed unrestricted access to such resources. This too has been studied extensively, leading organisations such as the Centres for Disease Control and Prevention in the United States (US) to develop a myriad of programmes targeting the social determinants of health in underserved communities. Similarly, on the healthcare systems end, limitations in resources result in unequal outcomes. Rural and county hospitals experiencing personnel shortages, overwhelming demand for operative treatment, and limited financial assets, tend to fare worse than their counterparts in outcomes such as post-operative mortality. This is deeply concerning, given that rural and county hospitals often care for patients with more comorbidities and limited resources.
In the last year and a half, the COVID-19 pandemic has further strained an already stressed system in the US. As a result of personnel shortages, bed unavailability, and the precautionary delay of non-urgent operations, there is currently a significant backlog of desperately needed surgeries. Taken together, these factors have also led to the loss of revenue for academic and non-academic hospitals, jeopardising their ability to take care of patients in the future. Even so, the COVID-19 pandemic has not affected all hospitals equally. In the US, safety-net hospitals—which care for the uninsured and underserved—saw their profits dwindle, while their private counterparts experienced an increase in revenues. In part, this discrepancy is due to anticipatory financial planning by private hospitals, but it is also a result of the federal government’s pre-pandemic initiative to allocate relief funds to hospitals commensurate with their revenues. Additionally, because the safety-net patient population tends to be sicker, more vulnerable, and require more intensive resources, these patients have suffered disproportionately along with the very hospitals tasked with caring for them.
“Bridging the resource gap and the outcome chasm cannot be achieved in one day. Indeed, social inequities present barriers to patient care in healthcare systems around the world. ”
In response to this exacerbation of existing disparities, hospital systems around the world have taken steps to provide adequate care. After all, the consequences of complacency in the face of limited resources are dire. Backlog in the cancer referral pathway, for example, could cause a significant excess in death rates according to a study designed to measure the effects of delayed referral in the United Kingdom. To optimise resources, various techniques have been implemented to ensure surgical services can operate on as many patients as possible before their disease progresses. One such technique was deployed in a hospital in Hong Kong, which created a tiered system of cancer subtypes and assigned target completion times for the respective operations, leading to some alleviation of their waitlist burden. Furthermore, the National Comprehensive Cancer Network has provided guidelines for resource allocation and triaging systems during the COVID-19 pandemic. These guidelines help hospitals streamline their care so that they may treat as many surgical patients as possible given the realities of resource shortages. While endeavours such as these have eased some of the strain on healthcare institutions, systemic factors continue to unduly affect disadvantaged patients.
Bridging the resource gap and the outcome chasm cannot be achieved in one day. Indeed, social inequities present barriers to patient care in healthcare systems around the world. While steps have been taken to address these disparities, further investigation into potentially implementable solutions is more important now than ever. The goal of this pursuit is to ensure that all patients, regardless of their backgrounds or means, receive the surgical care they need.