New study provides domestic model for low-cost, high-quality surgical care

A new study published in the December issue of the Journal of the American College of Surgeons shows that a volunteer program providing low-risk outpatient surgical procedures can deliver safe and effective health care to patients in need. However, the study authors do caution that the program is not a long-term solution for dealing with the medically uninsured.

While Congress and the media continue to debate legislation regarding universal health care, patients without insurance struggle to obtain needed care as the safety-net of public hospitals and clinics is stretched thinner every day. Operation Access, a volunteer program coordinating uncompensated, low-risk outpatient access to surgical and specialty services for the uninsured in the California Bay Area, provides a case study on how low-cost outpatient surgical care can work. The researchers found that the program provided patients with quality care based on the Institute of Medicine's (IOM) six quality-of-care guidelines, which include: safety, efficiency, effectiveness, timeliness, patient-centered care and equitability.

"Operation Access and similar programs have expanded services in the absence of sweeping health care reform and can continue to help address the surgical and specialty care needs of the uninsured," said William P. Schecter, MD, FACS, professor of clinical surgery, University of California, San Francisco, who is a member of the medical staff at San Francisco General Hospital and Trauma Center. "However, these programs are not intended to be long-term solutions. To ensure timely, appropriate access and care for all patients in need, health care reform is still necessary."

Using the Operation Access database, researchers retrospectively reviewed all patients referred to the program from 1994 to 2008 and identified 5,459 patients who were eligible for services. Data were coded for demographics, diagnosis, procedure, complications and patient satisfaction. Primary outcomes were measured using quality-of-care guidelines from the IOM. These qualities were measured by reviewing surgical complications (safety); patient compliance and value of donated services (efficiency); time between referral to Operation Access, first appointment and intervention (timeliness); patient surveys and case managers abilities to serve as effective patient advocates (patient-centered) and demographics (equity). The researchers assessed the effectiveness of the program on multiple factors, including clinicians' ability to provide direct referrals to Operation Access, specialist evaluations and appropriate interventions provided to patients, and patient surveys.

The average patient age was 44 years old, and 43 percent were male. Non-elderly adults of working age represented 92.7 percent of patients, and 63.3 percent were of Latino race/ethnicity. In 2008, 70 percent of patient appointments involved an interpreter, and 95.9 percent of the time the Operation Access case manager spoke the patient's primary language.

There were 4,201 medical interventions, but 26.3 percent>

Of the 1,880 surgical procedures evaluated during the 15-year study, only 12 patients required hospitalization. The average length-of-stay for all patients admitted for a complication was 2.5 days (range: one to five days). Among the 345 patients scheduled for operative procedures in 2008, 94.8 percent were compliant, 3.8 percent failed to appear on the date of the procedure, 0.3 percent cancelled the day before the procedure, and an additional 1.1 percent were noncompliant with preoperative instructions. The median time from community clinic referral to first appointment with a surgeon was 68 calendar days. The median time from community referral to operative intervention was 83 calendar days.