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


Among 3326 patients with canceled elective procedures due to COVID-19, we did not find that cancellations in elective procedures were associated with increases in short-term patient mortality. Surgical procedures canceled immediately around the order, despite having lower reschedule and completion rates compared to previous years, yielded similar mortality rates to procedures that had been completed. Further, canceled elective surgical procedures were not associated with an increased probability of an ED visit soon after the scheduled date.

Overall, our results suggest first and foremost that clinicians engaged in effective decision making and were able to appropriately triage cases to balance the needs of patients and public health concerns. The vast majority of canceled cases were low-acuity cases with low rates of intra- and postoperative surgical complications, in healthier patients, and concentrated in ophthalmology and orthopedics. Although a few studies have examined the impact of postponing elective procedures on resource utilization, to our knowledge, this is the first study to examine what impact these delays have had on patient outcomes across a range of surgical and procedural specialties. Although most cases were common, high-volume low-acuity procedures, we also did not find an association with 90-day mortality in intermediate-acuity case cancellations. With limited information and guidance about what should constitute an elective procedure and substantial uncertainty about the dangers of COVID-19 early in the pandemic, our results suggest that clinicians were able to select elective procedures could be safely delayed in a pandemic without immediate adverse consequences on patient survival.

ED visits following surgeries in both inpatient and ambulatory settings are common and well documented.[19–21] With cancellations of procedures during the pandemic, the usual postoperative complications that drive these visits are no longer applicable, thus largely explaining why the national order to cancel elective surgical procedures was not associated with increased ED utilization when compared to previous years. Although one might surmise that patients with canceled procedures did not experience significant clinical consequences related to the delay (eg, pain, infection) that would prompt acute, unscheduled visits to the ED, recent unpublished evidence and published data suggests that during the early stages of the pandemic, patients may have deferred visits to the ED in an attempt to reduce exposure to the virus.[22] The Centers for Disease Control and Prevention found that ED visits declined 42% during the early months of the COVID-19 pandemic which is close to our estimate of a 46% drop in ED visits relative to the comparison group.[23] Furthermore, it is possible that patients were substituting face-to-face ED visits with alternative virtual care modalities to address low-acuity concerns. These shifts in acute care utilization due to COVID-19 likely bias our estimates of ED visits when compared to previous years.

Though our results support the notion that elective cases can be safely delayed, the data does not capture the effects on other measures of health including well-being, functional capacity, pain, and economic consequences.[4] Moreover, many of the surgical cases canceled due to COVID-19 were for conditions that would take longer than 90 days to manifest as harmful in easily measurable ways. For example, patients that went without a cataract removal or knee arthroscopy may have experienced pain or reduced quality of life for longer than would normally be necessary but did not progress to the point of experiencing one of the more extreme outcomes measured in our study. Future studies should monitor longer-term outcomes for various procedure types.

Currently, there are limited data to guide healthcare systems in resuming elective cases. As our findings suggest, cancellations will undoubtedly result in an increasing backlog of cases that will pose significant future scheduling and clinical challenges. In the following months, it will be crucial to continue monitoring equitable access to elective surgery, particularly for socioeconomically disadvantaged patients who may be less able to advocate for themselves and more likely to be lost to follow-up. Variations in case completion rates should also be assessed to identify potential structural barriers to equitable access and ensure a fair allocation of services.

This study has several limitations. First, the VA population is different from the general population, and patients are more likely to be male, older, and have more comorbidities.[24] Although these differences would likely make this population more likely to suffer adverse outcomes associated with delays, it is unclear if other populations would have similar experiences with canceled surgical cases due to COVID-19. Furthermore, our analysis was limited to VA data and did not include referrals to or care from non-VA or community providers due to lag in claims data. Surgeries performed at non-VA hospitals were, therefore, not included, though this was likely a rare occurrence given significantly limited access to outpatient specialty care in community settings during the pandemic. Similarly, ED visits to non-VA EDs were not captured and may undercount actual acute care visits. However, mortality outcomes were not impacted as death data was available regardless of location of death. Finally, despite a rich set of demographic and clinical factors used for matched controls, any matching procedure cannot rule out the possibility of residual confounding from unobserved factors.