[Skip to Content]
[Skip to Content Landing]

Association Between the COVID-19 Pandemic and Disparities in Access to Major Surgery in the US

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What is the association between the Centers for Medicare & Medicaid Services moratorium on elective operations during the first wave of the COVID-19 pandemic and changes in the monthly elective surgical case volumes among Black individuals, Asian individuals, and individuals of other races compared with White individuals?

Findings  In this cross-sectional study of 3 470 905 adults undergoing major surgery, the reduction in elective surgery case volumes during the Centers for Medicare & Medicaid Services moratorium was not greater for Black individuals, Asian individuals, and individuals of other races than for White individuals.

Meaning  These findings suggest that the early response to the pandemic did not increase disparities in access to surgical care.

Abstract

Importance  Racial minority groups account for 70% of excess deaths not related to COVID-19. Understanding the association of the Centers for Medicare & Medicaid Services’ (CMS’s) moratorium delaying nonessential operations with racial disparities will help shape future pandemic responses.

Objective  To evaluate the association of the CMS’s moratorium on elective operations during the first wave of the COVID-19 pandemic among Black individuals, Asian individuals, and individuals of other races compared with White individuals.

Design, Setting, and Participants  This cross-sectional study assessed a 719-hospital retrospective cohort of 3 470 905 adult inpatient hospitalizations for major surgery between January 1, 2018, and October 31, 2020.

Exposure  The first wave of COVID-19 infections between March 1, 2020, and May 31, 2020.

Main Outcomes and Measures  The main outcome was the association between changes in monthly elective surgical case volumes and the first wave of COVID-19 infections as a function of patient race, evaluated using negative binomial regression analysis.

Results  Among 3 470 905 adults (1 823 816 female [52.5%]) with inpatient hospitalizations for major surgery, 70 752 (2.0%) were Asian, 453 428 (13.1%) were Black, 2 696 929 (77.7%) were White, and 249 796 (7.2%) were individuals of other races. The number of monthly elective cases during the first wave was 49% (incident rate ratio [IRR], 0.49; 95% CI, 0.486-0.492; P < .001) compared with the baseline period. The relative reduction in unadjusted elective surgery cases for Black (unadjusted IRR, 0.99; 95% CI, 0.97-1.01; P = .36), Asian (unadjusted IRR, 1.08; 95% CI, 1.03-1.14; P = .001), and other race individuals (unadjusted IRR, 0.97; 95% CI, 0.95-1.00; P = .05) during the surge period compared with the baseline period was very close to the change in cases for White individuals. After adjustment for age, sex, comorbidities, and surgical procedure, there was still no evidence that the first wave of the pandemic was associated with disparities in access to elective surgery.

Conclusions and Relevance  In this cross-sectional study, the CMS’s moratorium on nonessential operations was associated with a 51% reduction in elective operations. It was not associated with greater reductions in operations for racial minority individuals than for White individuals. This evidence suggests that the early response to the pandemic did not increase disparities in access to surgical care.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: April 4, 2022.

Published: May 23, 2022. doi:10.1001/jamanetworkopen.2022.13527

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Glance LG et al. JAMA Network Open.

Corresponding Author: Laurent G. Glance, MD, Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 604, Rochester, NY 14642 (laurent_glance@urmc.rochester.edu).

Author Contributions: Dr Glance had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Glance, Chandrasekar, Stone, Dutton, McCormick, Wu, Eaton, Dick.

Acquisition, analysis, or interpretation of data: Glance, Chandrasekar, Shippey, Dutton, Shang, Lustik, Dick.

Drafting of the manuscript: Glance, Chandrasekar, Dutton, Shang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Glance, Shippey, Dick.

Obtained funding: Stone, Dick.

Administrative, technical, or material support: Shippey, Dutton, Eaton.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grant R01AG074492 from the National Institute on Aging and the Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry (Dr Shang, principal investigator).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
World Health Organization. World Health Statistics 2021: Monitoring Health for the SDGs: Sustainable Development Goals. World Health Organization; 2021. Accessed November 6, 2021. https://apps.who.int/iris/bitstream/handle/10665/342703/9789240027053-eng.pdf
2.
Iuliano  AD , Chang  HH , Patel  NN ,  et al.  Estimating under-recognized COVID-19 deaths, United States, March 2020-May 2021 using an excess mortality modelling approach.   Lancet Reg Health Am. 2021;1:100019. doi:10.1016/j.lana.2021.100019PubMedGoogle ScholarCrossref
3.
Bilinski  A , Emanuel  EJ .  COVID-19 and excess all-cause mortality in the US and 18 comparison countries.   JAMA. 2020;324(20):2100-2102. doi:10.1001/jama.2020.20717 PubMedGoogle ScholarCrossref
4.
Anderson  C . US health care from a global perspective: spending, use of services, prices, and health in 13 countries. Accessed August 13, 2021. https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective
5.
Cronin  CJ , Evans  WN .  Excess mortality from COVID and non-COVID causes in minority populations.   Proc Natl Acad Sci U S A. 2021;118(39):e2101386118. doi:10.1073/pnas.2101386118 PubMedGoogle ScholarCrossref
6.
Centers for Medicare & Medicaid Services. Non-emergent, elective medical services, and treatment recommendations. Accessed July 25, 2021. https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf
7.
American College of Surgeons. COVID-19: Guidance for triage of non-emergent surgical procedures. Accessed July 25, 2021. https://www.facs.org/covid-19/clinical-guidance/triage
8.
Prasad  NK , Englum  BR , Turner  DJ ,  et al.  A nation-wide review of elective surgery and COVID-surge capacity.   J Surg Res. 2021;267:211-216. doi:10.1016/j.jss.2021.05.028 PubMedGoogle ScholarCrossref
9.
Pirracchio  R , Mavrothalassitis  O , Mathis  M , Kheterpal  S , Legrand  M .  Response of US hospitals to elective surgical cases in the COVID-19 pandemic.   Br J Anaesth. 2021;126(1):e46-e48. doi:10.1016/j.bja.2020.10.013 PubMedGoogle ScholarCrossref
10.
Jha  AK , Fisher  ES , Li  Z , Orav  EJ , Epstein  AM .  Racial trends in the use of major procedures among the elderly.   N Engl J Med. 2005;353(7):683-691. doi:10.1056/NEJMsa050672 PubMedGoogle ScholarCrossref
11.
Birkmeyer  JD , Barnato  A , Birkmeyer  N , Bessler  R , Skinner  J .  The impact of the COVID-19 pandemic on hospital admissions in the United States.   Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980 PubMedGoogle ScholarCrossref
12.
Loehrer  AP , Chang  DC , Scott  JW ,  et al.  Association of the Affordable Care Act Medicaid expansion with access to and quality of care for surgical conditions.   JAMA Surg. 2018;153(3):e175568. doi:10.1001/jamasurg.2017.5568 PubMedGoogle ScholarCrossref
13.
Saad  M , Kennedy  KF , Imran  H ,  et al.  Association between COVID-19 diagnosis and in-hospital mortality in patients hospitalized with ST-segment elevation myocardial infarction.   JAMA. 2021;326(19):1940-1952. doi:10.1001/jama.2021.18890 PubMedGoogle ScholarCrossref
14.
von Elm  E , Altman  DG , Egger  M , Pocock  SJ , Gøtzsche  PC , Vandenbroucke  JP ; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Lancet. 2007;370(9596):1453-1457. doi:10.1016/S0140-6736(07)61602-X PubMedGoogle ScholarCrossref
15.
Centers for Disease Control and Prevention. 2021 NHSN ICD-10 operative procedure code mappings. Accessed August 9, 2021. https://www.cdc.gov/nhsn/xls/guidance-for-hpro-kpro-procedure-details.xlsx
16.
Cromwell  J , McCall  NT , Burton  J , Urato  C .  Race/ethnic disparities in utilization of lifesaving technologies by Medicare ischemic heart disease beneficiaries.   Med Care. 2005;43(4):330-337. doi:10.1097/01.mlr.0000156864.80880.aa PubMedGoogle ScholarCrossref
17.
Razavi  AC , Kelly  TN , He  J ,  et al.  Cardiovascular disease prevention and implications of coronavirus disease 2019: an evolving case study in the Crescent City.   J Am Heart Assoc. 2020;9(13):e016997. doi:10.1161/JAHA.120.016997 PubMedGoogle ScholarCrossref
18.
Nguyen  TC , Thourani  VH , Nissen  AP ,  et al.  The effect of COVID-19 on adult cardiac surgery in the United States in 717 103 patients.   Ann Thorac Surg. 2022;113(3):738-746. doi:10.1016/j.athoracsur.2021.07.015PubMedGoogle ScholarCrossref
19.
Malaisrie  SC , McDonald  E , Kruse  J ,  et al.  Mortality while waiting for aortic valve replacement.   Ann Thorac Surg. 2014;98(5):1564-1570. doi:10.1016/j.athoracsur.2014.06.040 PubMedGoogle ScholarCrossref
20.
Rexius  H , Brandrup-Wognsen  G , Odén  A , Jeppsson  A .  Mortality on the waiting list for coronary artery bypass grafting: incidence and risk factors.   Ann Thorac Surg. 2004;77(3):769-774. doi:10.1016/j.athoracsur.2003.05.007 PubMedGoogle ScholarCrossref
21.
Lurie  N , Dubowitz  T .  Health disparities and access to health.   JAMA. 2007;297(10):1118-1121. doi:10.1001/jama.297.10.1118 PubMedGoogle ScholarCrossref
22.
Lavizzo-Mourey  RJ , Besser  RE , Williams  DR .  Understanding and mitigating health inequities—past, current, and future directions.   N Engl J Med. 2021;384(18):1681-1684. doi:10.1056/NEJMp2008628 PubMedGoogle ScholarCrossref
23.
Olshansky  SJ , Antonucci  T , Berkman  L ,  et al.  Differences in life expectancy due to race and educational differences are widening, and many may not catch up.   Health Aff (Millwood). 2012;31(8):1803-1813. doi:10.1377/hlthaff.2011.0746 PubMedGoogle ScholarCrossref
24.
Angraal  S , Khera  R , Wang  Y ,  et al.  Sex and race differences in the utilization and outcomes of coronary artery bypass grafting among Medicare beneficiaries, 1999-2014.   J Am Heart Assoc. 2018;7(14):e009014. doi:10.1161/JAHA.118.009014 PubMedGoogle ScholarCrossref
25.
Skinner  J , Weinstein  JN , Sporer  SM , Wennberg  JE .  Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients.   N Engl J Med. 2003;349(14):1350-1359. doi:10.1056/NEJMsa021569 PubMedGoogle ScholarCrossref
26.
Epstein  AM , Ayanian  JZ , Keogh  JH ,  et al.  Racial disparities in access to renal transplantation–clinically appropriate or due to underuse or overuse?   N Engl J Med. 2000;343(21):1537-1544. doi:10.1056/NEJM200011233432106PubMedGoogle ScholarCrossref
27.
Arya  S , Binney  Z , Khakharia  A ,  et al.  Race and socioeconomic status independently affect risk of major amputation in peripheral artery disease.   J Am Heart Assoc. 2018;7(2):e007425. doi:10.1161/JAHA.117.007425 PubMedGoogle ScholarCrossref
28.
Glance  LG , Thirukumaran  CP , Dick  AW .  The unequal burden of COVID-19 deaths in counties with high proportions of Black and Hispanic residents.   Med Care. 2021;59(6):470-476. doi:10.1097/MLR.0000000000001522 PubMedGoogle ScholarCrossref
29.
Gornick  ME , Eggers  PW , Reilly  TW ,  et al.  Effects of race and income on mortality and use of services among Medicare beneficiaries.   N Engl J Med. 1996;335(11):791-799. doi:10.1056/NEJM199609123351106 PubMedGoogle ScholarCrossref
30.
Lucas  FL , Siewers  A , Goodman  DC , Wang  D , Wennberg  DE .  New cardiac surgery programs established from 1993 to 2004 led to little increased access, substantial duplication of services.   Health Aff (Millwood). 2011;30(8):1569-1574. doi:10.1377/hlthaff.2010.0210 PubMedGoogle ScholarCrossref
31.
Kwok  AC , Semel  ME , Lipsitz  SR ,  et al.  The intensity and variation of surgical care at the end of life: a retrospective cohort study.   Lancet. 2011;378(9800):1408-1413. doi:10.1016/S0140-6736(11)61268-3 PubMedGoogle ScholarCrossref
32.
Epstein  AJ , Gray  BH , Schlesinger  M .  Racial and ethnic differences in the use of high-volume hospitals and surgeons.   Arch Surg. 2010;145(2):179-186. doi:10.1001/archsurg.2009.268 PubMedGoogle ScholarCrossref
33.
Schpero  WL , Morden  NE , Sequist  TD , Rosenthal  MB , Gottlieb  DJ , Colla  CH .  For selected services, Blacks and Hispanics more likely to receive low-value care than Whites.   Health Aff (Millwood). 2017;36(6):1065-1069. doi:10.1377/hlthaff.2016.1416 PubMedGoogle ScholarCrossref
34.
Chen  CL , Lin  GA , Bardach  NS ,  et al.  Preoperative medical testing in Medicare patients undergoing cataract surgery.   N Engl J Med. 2015;372(16):1530-1538. doi:10.1056/NEJMsa1410846 PubMedGoogle ScholarCrossref
35.
Bundorf  MK , Gupta  S , Kim  C .  Trends in health insurance coverage during the COVID-19 pandemic.   JAMA Health Forum. 2021;2(9):e212487. doi:10.1001/jamahealthforum.2021.2487 Google ScholarCrossref
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close