Cardiac surgery outcomes worsen during COVID

Heart surgery during the COVID-19 pandemic took a turn for the worse, with higher cost and poorer survival regardless of people’s socioeconomic status, according to US data.

Looking at a registry capturing adult cardiac surgeries in Virginia, researchers found that cases during the pandemic were significantly associated with huge increases in risk-adjusted mortality (odds ratio [OR] 1.398, 95 percent confidence interval [CI] 1.179–1.657; p<0.001), cost (+$4,823; p<0.001), and failure to rescue (OR, 1.37, 95 percent CI, 1.10–1.70; p=0.005). [Ann Thorac Surg 2023; 115:1511-1518]

“A potential cause of increased rates of failure to rescue [and thereby, operative mortality] is resource strain, for example, staffing shortages and healthcare worker burnout, leading to suboptimal triage decisions and patient care,” said Dr Raymond Strobel, a cardiothoracic surgery resident at the University of Virginia in Charlottesville, Virginia, US, who presented results at STS 2024.

“Surprisingly, there was no statistically significant effect modification by the patient’s assigned Distressed Communities Index [DCI], which is a measure of socioeconomic well-being at the level of the patient’s home zip code,” he added.

“This means regardless of people’s socioeconomic status, their postoperative outcomes during the pandemic were negatively influenced in a similar way, whether they were from a more affluent or less affluent community,” Strobel said.

Does timing of surgery matter?

Strobel and his team analysed cardiac surgeries between July 2011 and May 2022 from a regional collaborative, the Virginia Cardiac Services Quality Initiative (VCSQI). Included were 37,769 patients from 17 centres.

Patients were stratified by timing of surgery (before vs during the COVID-19 pandemic in March 2020). Assessed were the relationship between COVID-19 and operative mortality, major morbidity, and cost, adjusting for DCI, Society of Thoracic Surgeons (STS) predicted risk of mortality, intraoperative characteristics, and hospital random effect.

Overall, 7,269 patients (19.7 percent) underwent surgery during the pandemic. On average, patients during the pandemic were less socioeconomically distressed (DCI, 37.4 vs DCI 41.9; p<0.001) and had a lower STS predicted risk of mortality (2.16 percent vs 2.53 percent; p<0.001).

After risk adjustment, the pandemic was significantly associated with increased mortality, cost, and STS failure to rescue across all socioeconomic statuses. The negative impact of the pandemic on mortality and cost was similar regardless of DCI.

“More patients who were able to undergo heart surgery during the pandemic were from less distressed communities, suggesting that the more vulnerable patients had trouble getting access to care such as cardiology appointments or bookings for surgery,” said Strobel.

Enhance social services, protocols

“It speaks to the need for programmes that provide social services such as transportation and access to a physician,” he pointed out. “Given the increase in postoperative failure to rescue, mortality, and the decline in patients from distressed communities seen during the COVID-19 pandemic, there clearly exists a need for evidence-based cardiac surgery protocols for resource-constrained settings, and particularly, infectious disease outbreaks.” 

Session discussant Dr Daniel Engelman from Baystate Medical Center in Springfield, Massachusetts, US, suggested potential roles of implicit or explicit provider bias on top of structural socioeconomic constraints.

Meanwhile, Dr Charles Fraser, Jr from Dell Medical School at the University of Texas, Austin, US noted the problem of nurse staffing, including reliance on traveling nurses, during the pandemic.

“Things may be improving now,” said Strobel. “While operative mortality is still relatively high, failure to rescue in the late pandemic era has dropped back down to pre-pandemic levels. Health systems are starting to catch up.”