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

Abstract

Surgical patients with perioperative COVID-19 infection experience higher rates of adverse events than those without COVID, 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 status is not considered. Data included 793,280 patient records from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from April 1, 2020 to March 31, 2021. Models predicting 30-day Mortality, Morbidity, Pneumonia, Ventilator Dependency > 48 hours, and unplanned intubation were constructed. Risk adjustment variables were selected for these models from standard NSQIP predictors and perioperative COVID status. 5,878 (0.66%) had preoperative COVID and 5,215 (0.58%) had postoperative COVID. COVID rates demonstrated some consistency across hospitals (median preoperative 0.84%, IQR=0.14%-0.84%; median postoperative 0.50%, IQR=0.24%-0.78%). Postoperative COVID was always associated with increased adverse events. For postoperative COVID among all cases, there was nearly a six-fold increase in Mortality (1.07% to 6.37%) and15-fold increase in Pneumonia (0.92% to 13.57%), excluding the diagnosis of COVID itself. The effects of preoperative COVID were less consistent. Inclusion of COVID in risk-adjustment models had minimal effects on surgical quality assessments. Perioperative COVID was associated with a dramatic increase in adverse events. However, quality benchmarking minimally affected. This may be the result of low overall COVID rates or balance in rates established across hospitals over the 1-year observational period. There remains limited evidence for restructuring ACS NSQIP risk-adjustment for the time-limited effects of the COVID pandemic.