Background
Prior studies suggest that marginalized or vulnerable patient populations may have been disproportionately affected by health care restrictions during the height of the COVID-19 pandemic. We sought to determine whether there were differences in patient selection and health care resource utilization for complex gastrointestinal (GI) surgeries such as esophagectomy, pancreatectomy, or hepatectomy during this period, compared to years immediately before and after the pandemic.
Methods
The American College of Surgeons (ACS) National Surgical Quality Improvement Project (NSQIP) participant use file was queried from 2018 to 2022 by Current Procedural Terminology (CPT) codes. Using these CPT codes, esophagectomy (43107, 43108, 43112, 43113, 43116-43118, 43121-43124), hepatectomy (47120, 47122, 47125, 47130, 47379), and pancreatectomy (48120, 48140, 48145, 48146, 48150, 48152-48155, 48160) cases were evaluated. The height of the COVID-19 pandemic was defined as the year 2020 (pandemic height) and compared to the two years immediately preceding and following. Statistical tests of association were utilized comparing patients in the pandemic height and outside this period. A two-sided p-value of 0.05 was defined as statistically significant and all analyses were conducted using Stata v17.
Results
A total of N=82,222 cases were included for analysis, after excluding cases performed emergently. Comparing the pandemic height to the period outside this time, there appeared to be differences in patient selection by race (Black patients 10.1% vs. 10.4%, P<0.001), Hispanic ethnicity (7.3% vs. 7.9%, P=0.010), obesity (31.5% vs. 32.6%, P=0.004), preoperative ascites (0.26% vs. 0.41%, P=0.006), history of congestive heart failure (0.46% vs. 1.37%, P<0.001), preoperative chronic renal failure (0.09% vs. 0.18%, P=0.017), and chronic steroid use (3.8% vs. 4.3%, P=0.002). With respect to health care utilization, there were more patients discharged home (93.8% vs. 92.8%, P<0.001) and decreased prolonged length of hospital stay defined as greater or equal to 8 days, which was the 75th percentile of length of stay for the cohort (32.6% vs. 33.6%, P=0.016), during the pandemic height than outside this period. There were no differences during the pandemic height and outside this period with respect to 30-day mortality (1.8% vs. 1.7%, P=0.297), readmission (13.6% vs. 13.7%, P=0.758), or reoperation (4.6% vs. 4.4%, P=0.245).
Discussion
There appeared to be disparities in patient selection for complex GI operations (esophagectomy, pancreatectomy, hepeatectomy) that may have been exacerbated by health care restrictions during the height of the COVID-19 pandemic. As centers move towards accreditation standards for complex GI surgery, it would be important to ensure equitable access to surgical care, even in times of health care system stress.
