Association between the COVID-19 Pandemic and Insurance-Based Disparities in Mortality after Major Surgery among US Adults

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 2950147 adults undergoing inpatient surgery (1550752 female [52.6%]) at 677 hospitals, the primary payer was Medicare (1427791 [48.4%]), followed by commercial insurance (1000068 [33.9%]), Medicaid (321600 [10.9%]), other payer (140959 [4.8%]), and no insurance (59729 [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