Influence of Perioperative COVID-19 Infection on Surgical Outcomes and Risk Adjustment for Quality Assessment in the American College of Surgeons NSQIP

Abstract

BACKGROUND: Surgical patients with perioperative coronavirus disease 19 (COVID-19) infection experience higher rates of adverse events than those without COVID-19, which may lead to imprecision in hospital-level quality assessment. Our objectives were to quantify differences in COVID-19–associated adverse events in a large national sample and examine distortions in surgical quality benchmarking if COVID-19 status is not considered. STUDY DESIGN: Data included 793,280 patient records from the American College of Surgeons NSQIP from April 1, 2020, to March 31, 2021. Models predicting 30-day mortality, morbidity, pneumonia, and ventilator dependency greater than 48 hours, and unplanned intubation were constructed. Risk adjustment variables were selected for these models from standard NSQIP predictors and perioperative COVID-19 status. RESULTS: A total of 5,878 (0.66%) had preoperative COVID-19, and 5,215 (0.58%) had postoperative COVID-19. COVID-19 rates demonstrated some consistency across hospitals (median preoperative 0.84%, interquartile range 0.14% to 0.84%; median postoperative 0.50%, interquartile range 0.24% to 0.78%). Postoperative COVID-19 was always associated with increased adverse events. For postoperative COVID-19 among all cases, there was nearly a 6-fold increase in mortality (1.07% to 6.37%) and15-fold increase in pneumonia (0.92% to 13.57%), excluding the diagnosis of COVID-19 itself. The effects of preoperative COVID-19 were less consistent. Inclusion of COVID-19 in risk-adjustment models had minimal effects on surgical quality assessments. CONCLUSIONS: Perioperative COVID-19 was associated with a dramatic increase in adverse events. However, quality benchmarking was minimally affected. This may be the result of low overall COVID-19 rates or balance in rates established across hospitals during the 1-year observational period. There remains limited evidence for restructuring ACS NSQIP risk-adjustment for the time-limited effects of the COVID-19 pandemic.