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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.


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.

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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.

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