Short-Term Effects of Canceled Elective Procedures Due to COVID-19

Evidence From the Veterans Affairs Healthcare System

Linda Diem Tran, PhD, MPP; Liam Rose, PhD; Tracy Urech, MPH; Aaron Dalton, MA, MSW; Siqi Wu, MPH; Anita A. Vashi, MD, MPH, MHS


Annals of Surgery. 2021;274(1):45-49. 

In This Article

Abstract and Introduction


Objective: To determine whether delayed or canceled elective procedures due to COVID-19 resulted in higher rates of ED utilization and/or increased mortality.

Summary of Background Data: On March 15, 2020, the VA issued a nationwide order to temporarily pause elective cases due to COVID-19. The effects of this disruption on patient outcomes are not yet known.

Methods: This retrospective cohort study used data from the VA Corporate Data Warehouse. Surgical procedures canceled due to COVID-19 in 2020 (n = 3326) were matched to similar completed procedures in 2018 (n = 151,863) and 2019 (n = 146,582). Outcome measures included 30- and 90-day VA ED use and mortality in the period following the completed or canceled procedure. We used exact matching on surgical procedure category and nearest neighbor matching on patient characteristics, procedure year, and facility.

Results: Patients with elective surgical procedures canceled due to COVID-19 were no more likely to have an ED visit in the 30- [Difference: −4.3% pts; 95% confidence interval (CI): −0.078, −0.007] and 90 days (−0.9% pts; 95% CI: −0.068, 0.05) following the expected case date. Patients with cancellations had no difference in 30- (Difference: 0.1% pts; 95% CI: −0.008, 0.01) and 90-day (Difference: −0.4% pts; 95% CI: −0.016, 0.009) mortality rates when compared to similar patients with similar procedures that were completed in previous years.

Conclusions: The pause in elective surgical cases was not associated with short-term adverse outcomes in VA hospitals, suggesting appropriate surgical case triage and management. Further study will be essential to determine if the delayed cases were associated with longer-term effects.


The SARS-CoV-2 (COVID-19) pandemic caused an unprecedented interruption in healthcare delivery. Healthcare systems reallocated resources in anticipation of a surge and by mid-March, nearly every healthcare system had postponed, delayed, or canceled elective surgical procedures. Although it was almost universally acknowledged that curtailing procedures was necessary to reduce unnecessary exposure to the virus and to reallocate personnel, equipment, and resources for anticipated COVID-19 patients, there has been widespread concern that delays in care may have resulted in patient harm.[1]

On March 15, 2020, similar to many other healthcare systems, the Veterans Administration (VA) issued a nationwide order to temporarily pause elective cases for an indefinite period of time.[2] The American College of Surgeons issued triage guidance the next day to aid with decision making on which cases should proceed.[3] However, the term "elective" is broad and ill-defined and there is no consensus on what types of cases should proceed, and under what circumstances. Suggestions and advice regarding how to triage cases varied across regions and disciplines.[4] Up to 91% of surgical cases could be considered elective, but nearly all of these need to be completed at some point in the future.[5] As such, these decisions were primarily left up to local clinicians and leaders instead of issuing blanket guidance. For many institutions, including VA, case-by-case decisions determined which procedures proceeded both immediately after the pause and later as surgical cases resumed.

The consequences of delays in surgery are not well-understood. However, research to date suggests that delays can have functional, psychologic, and economic ramifications for patients.[4,6,7] Moreover, postponing care could lead to delays in diagnosis and treatment as disease burden continues to accumulate.[8,9] As patients and healthcare systems continue to face challenges during the ongoing pandemic and grapple with the back log of cases in the postsurge phase, it is vital to ascertain how delays in elective procedures impacted patients. To assess short-term adverse outcomes, we examined the association of canceled elective procedures with 30- and 90-day ED use and mortality among Veterans scheduled to have an elective procedure compared to similar patients with similar procedures in previous years.