Days alive and out of hospital in patients undergoing cardiac surgery during the COVID-19 pandemic

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Cardiac disease requiring non-emergency coronary artery bypass grafting (CABG) and/or valvular surgery (n=5630). Intervention: COVID-19 pandemic onset and directive to postpone elective surgery (post-March 15, 2020) vs. Pre-pandemic era (March 15, 2018 to March 15, 2020). Primary outcome: Days Alive and Out of Hospital at 90 days (DAOH-90) in isolated CABG cohort (immediate level change in monthly mean) (MD -0.93 days, 95% CI -3.03 to 1.17, p=0.39).

Q: What does this research mean for the field?

COVID-19 pandemic surgical postponement directives did not lead to a sustained, statistically significant change in 90-day days alive and out of hospital following cardiac surgery. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Justyna M Bartoszko; Louise Y. Sun; William Petrcich; Sarah J. Miles; Miki Peer; Maral Ouzounian; Vivek Rao; Wendy Tsang; Fayez A. Quereshy; Jacobo Moreno Garijo; Azad Mashari; Wilton A. van Klei

doi:10.1186/s12871-026-04378-7

October 23, 2026BMC AnesthesiologyOpen Access

Days alive and out of hospital in patients undergoing cardiac surgery during the COVID-19 pandemic

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Key result

Pandemic surgical directives show no sustained impact on 90-day days alive and out of hospital.

MD -0.93 days
95% CI -3.03 to 1.17
P=0.39
n=5,630

Why the study?

The impact of the COVID-19 pandemic on patient-centred outcomes after cardiac surgery, including differences by sex, income, and rurality, remained unclear.

Did the onset of COVID-19 pandemic-related health system changes and directives to postpone elective surgery reduce Days Alive and Out of Hospital at 90 days (DAOH-90) in adults undergoing non-emergency cardiac surgery?

Key Points

To evaluate whether Days Alive and Out of Hospital at 90 days (DAOH-90) changed among adult cardiac surgery patients following pandemic-related elective surgery postponement directives, and to explore disparities by sex, income, and rurality.
Retrospective cohort study of 5,630 adult patients (≥ 18 years) undergoing cardiac surgery across two tertiary centres in Ontario, Canada, between March 15, 2018, and March 15, 2022.
Procedures were categorized into isolated CABG (n=2,549), single valve (n=1,657), and complex surgery (n=1,424).
Evaluated monthly DAOH-90 trends using interrupted time-series (ITS) models with March 15, 2020, as the interruption point, alongside exploratory zero-inflated beta-binomial models for sociodemographic factors.
In primary ITS models, immediate changes in monthly mean DAOH-90 at the pandemic interruption were −0.93 days for CABG (SE 1.07; 95% CI −3.03 to 1.17; p=0.39), −2.82 days for single valve surgery (SE 1.21; 95% CI −5.19 to −0.45; p=0.03), and +0.79 days for complex surgery (SE 2.35; 95% CI −3.82 to 5.40; p=0.74).
Post-interruption slope changes were not statistically significant for CABG (+0.14 days/month), single valve (−0.04 days/month), or complex procedures (+0.13 days/month; all p ≥ 0.12), and the single valve immediate decrease attenuated in sensitivity analysis (−2.86 days, 95% CI −5.93 to 0.21; p=0.07).
Exploratory analyses showed female patients and those in the lowest two income quintiles had lower mean DAOH-90 before and during the pandemic, whereas rurality showed no significant association.

Study Design

Type

Cohort (n=5,630)

Multicenter

Yes

Structured PICO

Did the onset of COVID-19 pandemic-related health system changes and directives to postpone elective surgery reduce Days Alive and Out of Hospital at 90 days (DAOH-90) in adults undergoing non-emergency cardiac surgery?

P

Population

5,630 adults (27.7% female) undergoing non-emergency CABG, single valve, or complex cardiac surgery at two tertiary centers in Ontario, Canada, followed for 90 days postoperatively.

E

Exposure

Post-pandemic onset surgical period (March 15, 2020 to March 15, 2022), treated as a composite system-level exposure following the first Ontario Ministry of Health directive to postpone elective surgeries in response to the COVID-19 pandemic.

C

Comparator

Pre-pandemic surgical period (March 15, 2018 to March 14, 2020), prior to pandemic-related directives to postpone elective surgery.

O

Outcome

Days Alive and Out of Hospital at 90 days (DAOH-90) postoperatively, integrating mortality (death within 90 days assigned 0 days), index hospital length of stay, and hospital readmissions.composite

Main Result

Mean Difference: -0.93 (95% CI -3.03–1.17)

p-value: p=0.39

Despite health-system disruptions during the COVID-19 pandemic, patients undergoing non-emergency cardiac surgery did not experience a sustained reduction in Days Alive and Out of Hospital at 90 days, though persistent disparities were observed for female and lower-income patients.

Limitations

Includes only patients who ultimately underwent surgery and does not account for waitlist mortality or access delays associated with the pandemic.
Using a single interruption timepoint may oversimplify a complex, evolving pandemic environment and case-mix changes.
Pooling heterogeneous procedures (such as left-sided and right-sided valve surgeries) into broader analytic cohorts may obscure procedure-specific pandemic effects.
Potentially limited statistical power to detect small level or slope changes.
Retrospective observational design at two tertiary centers in one Canadian province limits causal inference and generalizability.

Implication

Pandemic directives showed no sustained DAOH-90 impact after cardiac surgery; hypothesis-generating for persistent sex and income disparities.

Abstract

The impact of the COVID-19 pandemic on patient-centred outcomes remains unclear. We evaluated Days Alive and Out of Hospital at 90 days (DAOH-90) in cardiac surgery patients, and assessed outcome differences based on sex, income, and rurality before and after the first local directive to postpone elective surgery. This was a retrospective cohort study including adults (≥ 18 years) at Toronto General Hospital and the University of Ottawa Heart Institute from March 15, 2018 to March 15, 2022. Analyses were conducted separately for coronary artery bypass grafting (CABG), isolated valve, and complex surgery (CABG with ≥ 1 valve or multivalve surgery without CABG). March 15, 2020, the date of the first Ontario directive to postpone elective surgery, was specified as the interruption in procedure-specific interrupted time-series (ITS) models of monthly DAOH-90. In an exploratory analysis, patient-level zero-inflated beta-binomial models model the association of sex, rurality, and neighbourhood income with the outcome. We included 5,630 patients [2549 (45%) CABG, 1657 (29%) single valve, and 1424 (25%) complex procedures]. There was no change in the DAOH-90 trend after pandemic onset. In ITS models, the changes in monthly mean DAOH-90 were − 0.93 days for CABG (SE 1.07; 95% CI − 3.03 to 1.17; p = 0.39), − 2.82 days for single valve surgery (SE 1.21; 95% CI − 5.19 to − 0.45; p = 0.03), and + 0.79 days for complex surgery (SE 2.35; 95% CI − 3.82 to 5.40; p = 0.74). Slope changes after the interruption were + 0.14, − 0.04, and + 0.13 days/month, respectively, and were not statistically significant (all p ≥ 0.12). In a sensitivity analysis, the single valve difference was attenuated and not statistically significant at the interruption (− 2.86 days, 95% CI − 5.93 to 0.21; p = 0.07). In the exploratory analysis, females had lower mean DAOH-90 for all procedures before and after pandemic onset, which was pronounced in the valve cohort. Patients in the two lowest income quintiles had lower mean DAOH-90 before and during the pandemic. Mean DAOH-90 was not associated with rurality. The specified ITS models did not demonstrate a sustained statistically significant change in monthly mean DAOH-90 after March 15, 2020. Not applicable.

Discussion

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Cite This Study

Bartoszko et al. (2026) conducted a cohort in Cardiac disease requiring non-emergency coronary artery bypass grafting (CABG) and/or valvular surgery (n=5,630). COVID-19 pandemic onset and directive to postpone elective surgery (post-March 15, 2020) vs. Pre-pandemic era (March 15, 2018 to March 15, 2020) was evaluated on Days Alive and Out of Hospital at 90 days (DAOH-90) in isolated CABG cohort (immediate level change in monthly mean) (MD -0.93 days, 95% CI -3.03 to 1.17, p=0.39). COVID-19 pandemic surgical directives did not cause a sustained change in 90-day days alive and out of hospital after CABG (-0.93 days, p=0.39), valve (-2.82, p=0.03), or complex surgery (+0.79, p=0.74).

synapsesocial.com/papers/6adc966ca704d151585a5e22 https://doi.org/10.1186/s12871-026-04378-7

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Days alive and out of hospital in patients undergoing cardiac surgery during the COVID-19 pandemic

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Days alive and out of hospital in patients undergoing cardiac surgery during the COVID-19 pandemic

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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