key: cord-0966946-1hhl6yzk
authors: Parcha, Vibhu; Kalra, Rajat; Glenn, Austin M.; Davies, James E.; Kuranz, Seth; Arora, Garima; Arora, Pankaj
title: Coronary Artery Bypass Graft Surgery Outcomes in the United States: Impact of COVID-19 Pandemic
date: 2021-03-30
journal: JTCVS open
DOI: 10.1016/j.xjon.2021.03.016
sha: 2a7d1464beef6dca29ccf0c02680a3d636695dbf
doc_id: 966946
cord_uid: 1hhl6yzk

Objective There has been a substantial decline in patients presenting for emergent and routine cardiovascular care in the United States after the onset of the coronavirus disease-2019 (COVID-19) pandemic. We sought to assess the risk of adverse clinical outcomes among patients undergoing coronary artery bypass graft (CABG) surgery during the 2020 COVID-19 pandemic period and compare the risks to those undergoing CABG prior to the pandemic in the year 2019. Methods A retrospective cross-sectional analysis of the TriNetX Research Network database was performed. Patients undergoing CABG between January 20, 2019, and September 15, 2019, contributed to the 2019 cohort, and those undergoing CABG between January 20, 2020, and September 15, 2020, contributed to the 2020 cohort. Propensity-score matching was performed, and the odds of mortality, acute kidney injury (AKI), stroke, acute respiratory distress syndrome (ARDS), and mechanical ventilation occurring by 30-days were evaluated. Results The number of patients undergoing CABG in 2020 declined by 35.5% from 5,534 patients in 2019 to 3,569 patients in 2020. After propensity-score matching, 3,569 patient pairs were identified in the 2019 and the 2020 cohorts. Compared with those undergoing CABG in 2019, the odds of mortality by 30-days were 0.96 (95%CI:0.69-1.33;p=0.80) in those undergoing CABG in 2020. The odds for stroke (OR:1.21 [95%CI:0.96-1.39]), AKI (OR: 0.76 [95%CI:0.59-1.08]), ARDS (OR:1.01 [95%CI:0.60-2.42]) and mechanical ventilation (OR: 1.11 [95% CI: 0.94-1.30]) were similar between the two cohorts. Conclusions The number of patients undergoing CABG in 2020 has substantially declined compared to 2019. Similar odds of adverse clinical outcomes was seen among patients undergoing CABG in the setting of COVID-19 compared with those in 2019.

Coronary artery disease remains a major cause of mortality in the United States despite there had been a precautionary postponement of elective procedures, including CABG, as part of 106 resource prioritization and infection control. 5, 6 However, delays in the performance of CABG 107 have been previously associated with increased mortality. 7 The procedural delays, combined 108 with the patients' reluctance to seek medical attention for cardiac symptoms during the evolution 109 of the pandemic, may impact the clinical outcomes in patients with coronary artery disease.

Data Source 118 We identified patients undergoing CABG at healthcare organizations contributing to the 119 TriNetX Research Network (Cambridge, MA). [8] [9] [10] [11] [12] [13] The TriNetX Research Network database is a 120 cloud-based HIPAA-compliant deidentified longitudinal patient-level federated electronic health 121 records (EHR) database. [8] [9] [10] [11] [12] [13] The data are available to researchers at participating health care 122 organizations and can be accessed at www.trinetx.com. The data integration is performed after 123 clearance through local data warehouses and research data repositories, prior to incorporation 124 into the TriNetX database. Data from inpatient, outpatient, and specialty services are contributed 125 by the participating organization. The structured data is mapped to standard and controlled 126 clinical terminology. Regular data quality assessment is performed to eliminate records that do 127 not adhere to quality standards and basic formatting requirements for adequate data 128 representation. The referential integrity of the data is ensured to ensure data comparability 129 across several databases. Regular monitoring of the temporal trend in data volume is also 130 monitored by the TriNetX software to ensure data validity. The stored and transmitted data in 

All statistical analyses were conducted using SAS 9.4 (Cary, NC). The baseline 162 characteristics of the study population were compared using descriptive statistics. Continuous 163 data were summarized as median with interquartile range, and categorical data were summarized 164 as counts and percentages. The categorical data were compared using the chi-square test, and 165 continuous data were compared using the Wilcoxon rank-sum test. Monthwise CABG procedure 166 counts in the two study periods was graphically tabulated. The monthwise COVID-19 167 hospitalizations recorded in the TriNetX research database were also graphically plotted.

Logistic regression was used to develop propensity-score matching models to obtain a propensity 169 score for each patient using and account for the differences in baseline characteristics. 8 The 170 model covariates included age, sex, race/ethnicity, body-mass index, alcohol abuse (ICD-10: 171 F10), asthma (J45), chronic obstructive pulmonary disease (COPD; J44.9), cerebrovascular 172 disease (I60-I69), chronic kidney disease (N18), diabetes mellitus (E08-E13), heart failure (I50), 173 hypertensive disease (I10-I16), ischemic heart disease (IHD; I20-I25), nicotine dependence 174 (F17), and any neoplasm (C00-D49). 8 Using a caliper of 0.1 pooled standard deviation, 1:1 175 nearest neighbor matching was performed. Logistic regression was used to estimate the odds of 176 the study outcomes. The comparative risks of study outcomes were summarized using odds 177 ratios (OR) with 95% confidence intervals (95% CI). The subgroup analysis of the 178 aforementioned study outcomes was done in a single-center cohort of patients identified from the 179 University of Alabama at Birmingham (UAB) and undergoing CABG in 2019 and 2020 during 180 the specified time period to verify the veracity of the outcomes of the larger database on an 181 institutional level. Statistical significance was determined by a two-sided type I error of 0.05.

In this study, we observed that there was a ~36% reduction in CABG procedure volume 212 between 2019 and 2020 (Figure 3) . The lowest number of CABG procedures occurred in April 213 2020, and there has been a gradual increase in the patients undergoing CABG in the setting of 214 the pandemic. We observed that the risks of mortality and adverse clinical outcomes by 30-days 215 following CABG were similar in patients undergoing CABG in 2019 and 2020 (Figure 4 ).

The COVID-19 pandemic has presented unique challenges for cardiac surgery services.

The healthcare policies were revised during the COVID-19 pandemic to conserve and prioritize 219 resources. The personnel, equipment, and critical care service limitations due to the pandemic 220 were presumed to impact the clinical outcomes in CABG patients. 6 We noted a substantial Our study findings may be limited by the use of administrative EHR data to identify the 253 study outcomes. There may be under coding of prevalent medical conditions such as IHD in the 254 EHR data. These limitations of EHR data have been described previously. 19, 20 Given the 255 observational nature of the study, there may also be residual confounding in our analysis due to unmeasured confounders. There may have been changes in the coding practices for 257 cardiovascular procedures over time that cannot be accounted for in these data. The decline in 258 CABG volume noted in our study may have been more profound in regions where the impact of 259 COVID-19 was more widespread. Since the TriNetX database deidentifies patients at the 260 individual and organizational level, we are unable to ascertain a clustering effect of COVID-19 261 on CABG volume. We were also unable to assess the disease severity, hemodynamic and There has been a substantial decline in CABG volume during the COVID-19 pandemic.

However, the risk of developing adverse clinical outcomes after CABG has not been affected by The figure depicts the density function of the cohorts before (Panel A) and after propensity-score matching (Panel B).

The figure depicts the frequency of the study outcomes in the propensity-score matched populations undergoing coronary artery bypass graft in 2019 and 2020.

The figure depicts the forest plot of odds ratios with confidence intervals for the study outcomes in the propensity-score matched populations undergoing coronary artery bypass graft in 2019 and 2020.

This figure describes the decline in the number of patients undergoing coronary artery bypass graft (CABG) surgery in the pre-pandemic (2019) and the pandemic period (2020). After propensity-score matching, 3,569 patient-pairs were identified, and the odds of the study outcomes were similar between the patients undergoing CABG in 2019 and 2020. The curves in this figure demonstrates the temporal trend in monthly coronary artery bypass graft (CABG) surgery cases in the 2019 (blue) and 2020 (orange) study periods.

The curves in this figure demonstrates the temporal trend in monthly COVID-19 hospitalization at the hospitals in the TriNetX database. 

hospital-accelerates-data-driven-approach-to-clinical-researchby-joining-the-trinetx-global-health-research-network-300601082.html 23 Children's Hospital

SARS-related coronavirus E gene [Presence] in Unspecified specimen by NAA with probe detection)[Positive] 94316-7 (SARS-CoV-2 (COVID-19) N gene [Presence] in Unspecified specimen by NAA with probe detection)[Positive] 94500-6 (SARS-CoV-2 (COVID-19) RNA [Presence] in Respiratory specimen by NAA with probe detection)[Positive] 94533-7 (SARS-CoV-2 (COVID-19) N gene [Presence] in Respiratory specimen by NAA with probe detection)[Positive] 94534-5 (SARS-CoV-2 (COVID-19) RdRp gene [Presence] in Respiratory specimen by NAA with probe detection)[Positive] 94502-2 (SARS-related coronavirus RNA [Presence] in Respiratory specimen by NAA with probe detection)[Positive] 94559-2 (SARS-CoV-2 (COVID-19) ORF1ab region [Presence] in Respiratory specimen by NAA with probe detection

Mechanical Ventilation 31500 (CPT: Intubation, endotracheal, emergency procedure) 5A1945Z (ICD10: Respiratory Ventilation, 24-96 Consecutive hours) 5A1955Z (ICD10: Respiratory Ventilation

0BH17EZ (ICD10: Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening) 0BH18EZ (ICD10: Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening Endoscopic) 1022227

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