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Health Disparities

Association Between the COVID-19 Pandemic and Insurance-Based Disparities in Mortality After Major Surgery Among US Adults

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Network Open

Published Online: July 18, 2022

Original Investigation

Article Information and Disclosures

Laurent G. Glance, MD^1,2,3;

Andrew W. Dick, PhD³;

Ernie Shippey, MS⁴;

Patrick J. McCormick, MD, MEng⁵;

Richard Dutton, MD, MBA⁶;

Patricia W. Stone, PhD, RN⁷;

Jingjing Shang, PhD, RN⁷;

Stewart J. Lustik, MD, MBA¹;

Heather L. Lander, MD¹;

Igor Gosev, MD, PhD⁸;

Karen E. Joynt Maddox, MD, MPH^9,10

Author Affiliations

¹Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
²Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
³RAND Health, RAND, Boston, Massachusetts
⁴Vizient Center for Advanced Analytics, Chicago, Illinois
⁵Memorial Sloan-Kettering Cancer Center, New York, New York
⁶US Anesthesia Partners, Dallas, Texas
⁷Center for Health Policy, Columbia School of Nursing, New York, New York
⁸Department of Surgery, University of Rochester School of Medicine, Rochester, New York
⁹Department of Medicine, Washington University in St Louis, Missouri
¹⁰Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, Missouri

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Key Points

Question Was the COVID-19 pandemic associated with greater changes in mortality after major surgery among patients with Medicaid insurance or without insurance compared with patients with commercial insurance?

Findings In this cross-sectional study of 2 950 147 adults undergoing major surgery, mortality rates among patients with Medicaid insurance and patients without insurance did not increase more than the rate among patients with commercial insurance in hospitals with a high COVID-19 burden compared with hospitals with a low COVID-19 burden.

Meaning These findings suggest that the early phase of the pandemic was not associated with increases in insurance-based disparities in mortality after major surgery.

Abstract

Importance The COVID-19 pandemic caused significant disruptions in surgical care. Whether these disruptions disproportionately impacted economically disadvantaged individuals is unknown.

Objective To evaluate the association between the COVID-19 pandemic and mortality after major surgery among patients with Medicaid insurance or without insurance compared with patients with commercial insurance.

Design, Setting, and Participants This cross-sectional study used data from the Vizient Clinical Database for patients who underwent major surgery at hospitals in the US between January 1, 2018, and May 31, 2020.

Exposures The hospital proportion of patients with COVID-19 during the first wave of COVID-19 cases between March 1 and May 31, 2020, stratified as low (≤5.0%), medium (5.1%-10.0%), high (10.1%-25.0%), and very high (>25.0%).

Main Outcomes and Measures The main outcome was inpatient mortality. The association between mortality after surgery and payer status as a function of the proportion of hospitalized patients with COVID-19 was evaluated with a quasi-experimental triple-difference approach using logistic regression.

Results Among 2 950 147 adults undergoing inpatient surgery (1 550 752 female [52.6%]) at 677 hospitals, the primary payer was Medicare (1 427 791 [48.4%]), followed by commercial insurance (1 000 068 [33.9%]), Medicaid (321 600 [10.9%]), other payer (140 959 [4.8%]), and no insurance (59 729 [2.0%]). Mortality rates increased more for patients undergoing surgery during the first wave of the pandemic in hospitals with a high COVID-19 burden (adjusted odds ratio [AOR], 1.13; 95% CI, 1.03-1.24; P = .01) and a very high COVID-19 burden (AOR, 1.38; 95% CI, 1.24-1.53; P < .001) compared with patients in hospitals with a low COVID-19 burden. Overall, patients with Medicaid had 29% higher odds of death (AOR, 1.29; 95% CI, 1.22-1.36; P < .001) and patients without insurance had 75% higher odds of death (AOR, 1.75; 95% CI, 1.55-1.98; P < .001) compared with patients with commercial insurance. However, mortality rates for surgical patients with Medicaid insurance (AOR, 1.03; 95% CI, 0.82-1.30; P = .79) or without insurance (AOR, 0.85; 95% CI, 0.47-1.54; P = .60) did not increase more than for patients with commercial insurance in hospitals with a high COVID-19 burden compared with hospitals with a low COVID-19 burden. These findings were similar in hospitals with very high COVID-19 burdens.

Conclusions and Relevance In this cross-sectional study, the first wave of the COVID-19 pandemic was associated with a higher risk of mortality after surgery in hospitals with more than 25.0% of patients with COVID-19. However, the pandemic was not associated with greater increases in mortality among patients with no insurance or patients with Medicaid compared with patients with commercial insurance in hospitals with a very high COVID-19 burden.

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Article Information

Accepted for Publication: May 23, 2022.

Published: July 18, 2022. doi:10.1001/jamanetworkopen.2022.22360

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 and Mr Shippey had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Glance, Dick, Shippey, McCormick, Dutton, Stone, Lander.

Acquisition, analysis, or interpretation of data: Dick, Shippey, McCormick, Dutton, Shang, Lustik, Lander, Gosev, Joynt Maddox.

Drafting of the manuscript: Glance, Shippey, Dutton, Lander.

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

Statistical analysis: Glance, Dick, Shippey.

Obtained funding: Glance, Dick, Stone.

Administrative, technical, or material support: Shippey, McCormick, Lander.

Conflict of Interest Disclosures: Dr Glance reported receiving grants from the National Institutes of Health during the conduct of the study. Dr McCormick reported receiving grants from the National Cancer Institute during the conduct of the study and serving as a committee or board member for the American Society of Anesthesiology, Anesthesia Quality Institute, Society for Technology in Anesthesia, SNOMED International, and The New York State Society of Anesthesiologists Inc outside the submitted work. Dr Stone reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Shang reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Lander reported receiving grants from Finger Lakes Geriatric Education Center outside the submitted work. Dr Joynt Maddox reported receiving grants from the National Heart, Lung, and Blood Institute and the National Institute on Aging and personal fees from Centene Corp Health Policy Advisory Council outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grant R01AG074492 from the National Institutes of Health (Drs Glance, Dick, Stone, and Shang) and the Department of Anesthesiology and Perioperative Medicine at the University of Rochester School of Medicine and Dentistry (Drs Glance, Lustik, and Lander).

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.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.