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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
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.

References
1.
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
2.
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
3.
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
4.
LaPar  DJ , Bhamidipati  CM , Mery  CM ,  et al.  Primary payer status affects mortality for major surgical operations.   Ann Surg. 2010;252(3):544-550. doi:10.1097/SLA.0b013e3181e8fd75 PubMedGoogle ScholarCrossref
5.
LaPar  DJ , Stukenborg  GJ , Guyer  RA ,  et al.  Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting.   Circulation. 2012;126(11)(suppl 1):S132-S139. doi:10.1161/CIRCULATIONAHA.111.083782 PubMedGoogle ScholarCrossref
6.
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
7.
Cohen  RAMM , Cha  AE , Terlizzi  EP . Health insurance coverage: early release of estimates from the National Health Interview Survey, January-June 2021. National Center for Health Statistics. 2021. Accessed December 29, 2021. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202111.pdf
8.
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
9.
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
10.
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
11.
de Havenon  A , Ney  JP , Callaghan  B ,  et al.  Characteristics and outcomes among US patients hospitalized for ischemic stroke before vs during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(5):e2110314. doi:10.1001/jamanetworkopen.2021.10314 PubMedGoogle ScholarCrossref
12.
Chinn  J , Sedighim  S , Kirby  KA ,  et al.  Characteristics and outcomes of women with COVID-19 giving birth at US academic centers during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(8):e2120456. doi:10.1001/jamanetworkopen.2021.20456 PubMedGoogle ScholarCrossref
13.
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
14.
2021 NHSN ICD-10 operative procedure code mappings. 2021. Accessed August 9, 2021. https://www.cdc.gov/nhsn/xls/guidance-for-hpro-kpro-procedure-details.xlsx
15.
Nuzzo  JB , Gostin  LO .  The first 2 years of COVID-19: lessons to improve preparedness for the next pandemic.   JAMA. 2022;327(3):217-218. doi:10.1001/jama.2021.24394 PubMedGoogle ScholarCrossref
16.
Sun  BC , Hsia  RY , Weiss  RE ,  et al.  Effect of emergency department crowding on outcomes of admitted patients.   Ann Emerg Med. 2013;61(6):605-611.e6. doi:10.1016/j.annemergmed.2012.10.026 PubMedGoogle ScholarCrossref
17.
Kadri  SS , Sun  J , Lawandi  A ,  et al.  Association between caseload surge and COVID-19 survival in 558 U.S. hospitals, March to August 2020.   Ann Intern Med. 2021;174(9):1240-1251. doi:10.7326/M21-1213 PubMedGoogle ScholarCrossref
18.
CMS releases recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during COVID-19 response. Published 2020. Accessed January 10, 2021. https://www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental
19.
Mattingly  AS , Rose  L , Eddington  HS ,  et al.  Trends in US surgical procedures and health care system response to policies curtailing elective surgical operations during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(12):e2138038. doi:10.1001/jamanetworkopen.2021.38038 PubMedGoogle ScholarCrossref
20.
Mackey  K , Ayers  CK , Kondo  KK ,  et al.  Racial and ethnic disparities in COVID-19–related infections, hospitalizations, and deaths: a systematic review.   Ann Intern Med. 2021;174(3):362-373. doi:10.7326/M20-6306PubMedGoogle ScholarCrossref
21.
Rosen  H , Saleh  F , Lipsitz  S , Rogers  SO  Jr , Gawande  AA .  Downwardly mobile: the accidental cost of being uninsured.   Arch Surg. 2009;144(11):1006-1011. doi:10.1001/archsurg.2009.195 PubMedGoogle ScholarCrossref
22.
Baker  DW , Sudano  JJ , Albert  JM , Borawski  EA , Dor  A .  Lack of health insurance and decline in overall health in late middle age.   N Engl J Med. 2001;345(15):1106-1112. doi:10.1056/NEJMsa002887 PubMedGoogle ScholarCrossref
23.
Memtsoudis  SG , Sun  X , Chiu  YL ,  et al.  Perioperative comparative effectiveness of anesthetic technique in orthopedic patients.   Anesthesiology. 2013;118(5):1046-1058. doi:10.1097/ALN.0b013e318286061d PubMedGoogle ScholarCrossref
24.
Waits  SA , Reames  BN , Sheetz  KH , Englesbe  MJ , Campbell  DA  Jr .  Anticipating the effects of Medicaid expansion on surgical care.   JAMA Surg. 2014;149(7):745-747. doi:10.1001/jamasurg.2014.222 PubMedGoogle ScholarCrossref
25.
Torain  MJ , Maragh-Bass  AC , Dankwa-Mullen  I ,  et al.  Surgical disparities: a comprehensive review and new conceptual framework.   J Am Coll Surg. 2016;223(2):408-418. doi:10.1016/j.jamcollsurg.2016.04.047PubMedGoogle ScholarCrossref
26.
Althoff  LEF , Ganapati  S , Walsh  C . The geography of remote work. National Bureau of Economic Research. 2021. Accessed January 11, 2022. https://www.nber.org/papers/w29181
27.
Bundorf  MK , Gupta  S , Kim  C .  Trends in health insurance coverage during the COVID-19 pandemic.   JAMA Health Forum. 2021;2(9):1-10. doi:10.1001/jamahealthforum.2021.2487 Google ScholarCrossref
28.
Romano  PS , Schembri  ME , Rainwater  JA .  Can administrative data be used to ascertain clinically significant postoperative complications?   Am J Med Qual. 2002;17(4):145-154. doi:10.1177/106286060201700404 PubMedGoogle ScholarCrossref
29.
Lawson  EH , Louie  R , Zingmond  DS ,  et al.  A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications.   Ann Surg. 2012;256(6):973-981. doi:10.1097/SLA.0b013e31826b4c4f PubMedGoogle ScholarCrossref
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 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

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

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