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


Sample Characteristics and Case Selection

Supplementary Table 1, presents descriptive statistics for the final analytic sample of 3326 patients with canceled elective procedures due to COVID-19 in 2020 and 298,445 matched patients with completed cases during March–June of 2018 and 2019. A slightly higher proportion of patients who had surgical procedures canceled due to COVID-19 were Black (20.8%) compared to patients whose surgical procedures were completed (18.6%, P = 0.002). Although mean age for both groups was 64 years, patients who had surgeries canceled on average had fewer Elixhauser comorbidities (mean: 3.3 vs 4.2, standardized difference: 0.34) and lower Nosos risk scores (mean: 1.7 vs 2.1, standardized difference: 0.18).

The surgical services with the most cancellations due to COVID-19 were ophthalmology, general surgery, and orthopedic cases (Table 1). Ophthalmology cases represented 25.7% of COVID-19 canceled cases and 20.4% of matched completed cases in 2018 and 2019. Supplementary Table 2, lists the most frequently canceled elective procedures, including lens and cataract procedures (779, 23.4%), knee arthroplasties (166, 5.0%), colonoscopies (166, 5.0%), and therapeutic procedures on muscles and tendons (149, 4.5%). Supplementary Table 3, describes the operative complexity for the completed and canceled procedures. Complex procedures (27, 0.8%) represented small fractions of canceled procedures, with standard complexity being the large majority (intermediate complexity: 483, 14.6%; standard complexity: 2792, 84.6%).

Risk of Emergency Department use

Unadjusted 30- and 90-day ED use were lower among patients who had their procedures canceled due to COVID-19 (90-day, 424/3326, 12.8%) compared to patients who had procedures completed in 2018 or 2019 (63,335/315,713, 20.1%). Matching results show that procedure cancellations due to COVID-19 were associated with lower 30- and 90-day ED use (Table 1). Compared to similar patients who had the same procedure completed in 2018 and 2019, 30- and 90-day ED use among patients who had their cases canceled were on average 4.3 [95% confidence interval (CI): −0.078, −0.007] and 0.9 (95% CI: −0.068, 0.05) percentage points lower, respectively. Compared to the mean ED visit rate in previous years, this represents a 41.3 and 4.6 percent drop relative to previous years. Patients who had intermediate operative complexity procedures canceled were significantly less likely to have an ED visit within 30 days of their scheduled surgical cases.

Risk of Mortality

Twenty-six or 0.8% of patients who had canceled procedures died within 90 days of the scheduled surgery date. The unadjusted 90-day mortality rate for patients whose surgical cases were not canceled was 1.5% (4,649). Cancellations were not significantly associated with higher 30- and 90-day mortality (Table 2). Compared to matched patients, 30-day mortality rate for patients who had cancellations was, on average, 0.1 percentage points higher and not statistically significant (Difference = 0.001; 95% CI: –0.008, 0.01). The estimate for 90-day mortality was also not statistically different between patients with cancellations and matched patients (Difference = –0.004% pts; 95% CI: –0.016, 0.009). Cancellations were also not significantly associated with higher short-term mortality rates relative to surgical case completion in cases with intermediate operative complexity, although fewer of these cases were canceled and estimates were less precise (30-day Difference = 0.015; 95% CI: –0.072, 0.101; 90-day Difference = 0.034; 95% CI: –0.054, 0.122). Cases assessed by VASQIP similarly did not show any statistically significant association (30-day Difference = –0.002; 95% CI: –0.041 to 0.037; 90-day Difference = –0.003; 95% CI: –0.043 to 0.036). The sensitivity analysis, which was limited to patients who had their cases canceled only on March 16–17, produced similar results (see Supplemental Tables 4 and 5,

Completion Rate

In 2018 and 2019, 22.0% (4,070) of elective procedures canceled in March–June were rescheduled and completed within 30 days of the initial case date; nearly one-third (5918, 32.0%) were completed within 90 days at VA facilities. Rescheduling surgical cases canceled due to COVID-19 lagged as the VA continues to adapt to the pandemic. Of the 3326 canceled cases, 67 (2.0%) procedures were completed within 30 days; 494 (14.9%) within 90 days (Table 3). Intermediate operative complexity procedures were slightly more likely to be rescheduled and completed than standard operative complexity procedures within 30 days (3.0% vs 1.8%).