Background COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System. Methods We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March–September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status. Results During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97–1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97–1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care. Conclusions We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.

Cells face competing metabolic demands. These include efficient use of both limited substrates and limited proteome capacity, as well as flexibility to deal with different environments. Flexibility requires spare enzyme capacity, which is proteome inefficient. ATP generation can occur via fermentation or respiration. Fermentation is much less substrate-efficient, but often assumed to be more proteome efficient, thereby favoring fast-growing cells engaging in aerobic glycolysis. Here, however, we show that mitochondrial respiration is actually more proteome-efficient than aerobic glycolysis. Instead, aerobic glycolysis arises from cells maintaining the flexibility to grow also anaerobically. These conclusions emerged from an unbiased assessment of metabolic regulatory mechanisms, integrating quantitative metabolomics, proteomics, and fluxomics, of two budding yeasts, Saccharomyces cerevisiae and Issatchenkia orientalis, the former more fermentative and the latter respiratory. Their energy pathway usage is largely explained by differences in proteome allocation. Each organism's proteome allocation is remarkably stable across environmental conditions, with metabolic fluxes predominantly regulated at the level of metabolite concentrations. This leaves extensive spare biosynthetic capacity during slow growth and spare capacity of their preferred bioenergetic machinery when it is not essential. The greater proteome-efficiency of respiration is also observed in mammals, with aerobic glycolysis occurring in yeast or mammalian cells that maintain a fermentation-capable proteome conducive to both aerobic and anaerobic growth.

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