Abstract

Introduction

The spread of the COVID-19 virus across the country and throughout the world has greatly impacted health care systems and interrupted delivery of elective hip and knee joint arthroplasty. With efforts to minimize viral transmission and conserve hospital resources, the American College of Surgeons, Centers for Medicare and Medicaid Services (CMS) and state regulations recommended postponing or canceling nonessential surgeries beginning in March 2020,¹ with reimbursement losses estimated at $17.0 billion per month.² It was estimated that approximately 30 000 primary and 3000 revision hip and knee elective arthroplasties would be canceled nationally each week³. These CMS regulations were updated in April 2020 and allowed states or regions that met specific safety criteria regarding facilities and case numbers to resume essential, non-COVID-19-related care.⁴

The hospital at the current study site resumed elective procedures in May 2020 following a state-wide decrease and stabilization in COVID-19 cases, along with the implementation of safety standards including adequate personal protective equipment, staffing, available testing and sanitation protocols.⁵ Even after procedures were permitted to resume, several factors may have influenced patients’ decisions to reschedule surgery during the height of a pandemic. Perhaps most notably may have been the perceived risk of contracting the virus and the potential for an increased risk of serious complication due to age, race, or pre-existing comorbidities. Additionally, with an average of 11 100 unemployment claims filed per week in May and a peak average of 30 400 claims filed per week in the prior month of April, loss of insurance, and additional financial burdens may have limited patient access to surgery.⁵ Despite these barriers, the severity of osteoarthritis and its impact on quality of life and function remained significant burdens to patients in need of surgery. This is especially important since delaying surgery has been shown to increase post-operative opioid use, lower clinical results and satisfaction, increase readmission rates, and prolong work absences.⁶

The influence of canceling months of elective procedures may be felt for years to come, and it is unknown how the pandemic has affected both provider ability to equitably serve the osteoarthritic patient population and patient access to receiving necessary treatment. Therefore, the purpose of this study was to (1) report the number of months for arthroplasty caseload to return to pre-pandemic levels, (2) compare pre- and post-shutdown patient demographics, and (3) evaluate if pre-operative patient-reported measures were different throughout the pandemic.

Materials and Methods

This was a secondary analysis of prospectively collected data for an on-site, Western Institutional Review Board approved joint registry. Patients having undergone elective joint arthroplasty by a single, fellowship trained orthopedic surgeon between January 2019 and April 2021 were included in the final data analysis. During the study period, elective procedures were cancelled from mid-March 2020 to May 2020; therefore, 517 consecutive patients were evaluated prior to the shutdown (Phase 1) and 398 consecutive patients following the restart of elective procedures. The clinic “recovery” following the shutdown (Phase 2) was defined from surgery restart to when the monthly caseload surpassed the average caseload reported for Phase 1; the remaining cases would be designated as Phase 3. As recommended by the American Association of Hip and Knee Surgeons⁷, all patients completed 2 patient reported outcomes pre-operatively: (1) hip disability and osteoarthritis outcome score, joint replacement (HOOS JR) or knee injury osteoarthritis outcome survey, joint replacement (KOOS JR) for hip and knee arthroplasty, respectively, and (2) Patient-Reported Outcomes Measurement Information System® from which Global Physical Health (GPH) and Global Mental Health (GMH) were determined. Following the restart of elective procedures, pre-operative instructional group classes were transitioned to an individual telephone call. Therefore, if no surveys were on file within the last 6 months, the patient was either mailed a survey or the survey was completed over the phone with a member of the orthopedic staff.

Self-identified ethnicity at the time of surgery was collected and classified as Asian, Native Hawai‘i/Pacific Islander (NH/PI), White, and Other/Not Disclosed. Patient demographics, including age, gender, and body mass index (BMI), and hospital length of stay (LOS) were collected during a manual chart review. Comorbidities were summarized by American Society of Anesthesiologist (ASA) category, as assigned by a core group of experienced anesthesiologists as part of the Perioperative Surgical Home.⁸ Patient insurance was also collected and categorized as (1) Medicare, (2) Medicaid, (3) Private and (4) Other. Descriptive statistics, including mean, standard deviations and frequencies, were determined for each Phase. Continuous and categorical variables were evaluated by multiple analyses of variance (ANOVA) and Chi-Squared tests, respectively, with a significance level of P<.05. For significant ANOVA main effects, a pairwise post-hoc analysis was performed with a Bonferroni correction. The effect size was calculated by eta squared (η²) tests for significant ANOVA main effects. All statistical analyses were performed on IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY) with a significance level of P<.05.

Results

The number of primary arthroplasty cases per month is presented in Figure 1. The average monthly caseload in 2019 was 36 patients per month. The clinic returned to a comparable caseload of 37 patients during September 2020, marking the end of Phase 2. Overall, there were 517 patients (376 unilateral and 141 bilateral) in the Phase 1 cohort (January 2019 to March 2020), 121 patients (93 unilateral and 28 bilateral) in the Phase 2 cohort (May 2020 to September 2020), and 277 patients (199 unilateral and 78 bilateral) in the Phase 3 cohort (October 2020 to April 2021). No significant differences in age, gender, BMI, or ASA score were found between the 3 groups (P >.05) (Table 1). There was a significant difference in ethnicity between time periods (P =.004), with a decrease in the proportion of NH/PI patients from Phase 1 to Phase 2. Length of stay for unilateral joint arthroplasty was significantly different (P <.001; η²=0.20), with Phase 2 (P <.001) and Phase 3 patients (P =.001) having a shorter length of stay. No difference in LOS was seen for patients undergoing bilateral procedures. Additionally, there was no difference in insurance payor type between the 3 groups (P =.53).

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Figure 1.

Total Number of Patients Receiving Arthroplasties by Month

Black bars = prior to the shutdown (Phase 1); Dark Gray bars = Phase 2, immediately following resumption of cases; Gray bars = Phase 3. Solid bars = unilateral arthroplasty; Lined bars = bilateral arthroplasty

A preliminary analysis was conducted to determine if differences existed between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) patient reported outcomes. There were no group differences in KOOS JR score during Phase 1 (P=.062), Phase 2 (P =.22) and Phase 3 (P =.90) or for the GPH (P >.53) or GMP (P >.55). Due to the lack of significant differences, UKA and TKA patient reported outcomes were combined. Self-reported pre-operative scores for HOOS JR/KOOS JR, GPH and GMH are presented in Figures 2-​-4,4, with means and standard deviations presented in Table 1. There were no differences in pre-operative HOOS Jr (P =.42) or KOOS Jr (TKA, P =.55; UKA, P =.13) scores across the 3 periods. There were also no differences in GPH (P =.38) or GMH (P =.08) between the time periods.

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Figure 2.

Average Pre-operative HOOS Jr and KOOS Jr Scores by Month for Hip and Knee Arthroplasties, Respectively

Black = Phase 1, prior to shutdown; Dark Gray = Phase 2, following reopening; Gray = Phase 3.

Dotted lines indicate the average scores over each respective time frame.

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Figure 4.

Average Pre-operative Global Mental Health (GMH) Scores by Month

Black = Phase 1, prior to shut down; Dark Gray = Phase 2, following reopening; Gray = Phase 3.

Dotted lines indicate the average scores over each respective time frame.

Discussion

The COVID-19 pandemic prompted many healthcare facilities to postpone non-essential treatment, which halted the delivery of care for elective joint arthroplasty. While the orthopedic center at the current study site was able to return to its usual procedural caseload within just 5 months of reopening, discrepancies between pre- and post-shutdown populations, if present, could indicate that COVID-19 had an inequitable effect on certain demographics regarding elective joint arthroplasty. Therefore, this study aimed to investigate whether any discrepancies existed in the demographic make-up and pre-operative condition of patients seeking operative treatment during Phase 2 and Phase 3. The results of the current study showed no concerning inconsistencies across these periods, suggesting that the current orthopedic center was able to achieve a timely recovery and serve a population comparable to the one seen prior to the pandemic.

While the demographic breakdown across the 3 time periods was generally consistent, the current study did find a slight decrease in NH/PI patients returning for surgery in the initial months after reopening. This downward trend was likely a consequence of the ethnic disparities in COVID-19 rates seen in the state of Hawai‘i. Statewide statistics demonstrated that Native Hawaiian and Pacific Islander populations each comprised 20% of the COVID-19 cases.9 The number of positive cases potentially represents a greater exposure risk, as multigenerational or multi-family member households are common in these populations. Furthermore, while only constituting 4% of Hawai‘i’s population, Pacific Islanders accounted for 28% of the state’s COVID-19-related hospitalizations, surpassing that of any other ethnicity.10 These high hospitalization rates represent a greater susceptibility to severe symptoms, likely attributed to a greater prevalence of chronic diseases.9 The disproportionate representation of cases and hospitalizations in NH/PI populations may have created hesitation in returning to health care facilities and a willingness to delay surgery due to the perceived risk of COVID-19 and subsequent complications. The increasing number of NH/PI patients in Phase 3, trending back towards pre-pandemic proportions, was encouraging, as proper safety precautions and patient messaging limited significant exacerbation of demographic disparities in patient access to elective joint arthroplasty.

In addition to the demographics mentioned above, insurance payor was a key area of interest in this study given the large spikes in unemployment claims filed in the state of Hawai‘i, specifically preceding the month when elective surgeries resumed. However, the results showed no differences in the proportion of private to public insurance payors between the 3 patient cohorts. This is consistent with the fact that the average age of patients receiving surgery during the pandemic remained above 65 years and reflects the prevalence of Medicare coverage, which would not be affected by changes to employment status. However, these results do not dismiss the possibility of other pandemic-related financial barriers influencing patients’ decisions to seek surgery.

This study also examined pre-operative patient-reported outcomes to assess arthritis severity and overall health. The average pre-operative HOOS Jr and KOOS Jr scores did not differ between the 3 phases, suggesting that patients choosing to undergo surgery during these 3 time periods were similar regarding pain and self-perceived function. Although not statistically significant, the GPH and GMH scores appeared slightly higher than average for patients choosing to undergo surgery during Phase 2. This may indicate that slightly higher-functioning, healthier, or more confident patients were more willing to return sooner for surgery despite fears associated with the pandemic. However, in Phase 3, GPH and GMH scores returned to similar levels reported before the pandemic shutdown began. With previous studies showing correlations between pre-operative mental health scores and functional outcomes following arthroplasty surgery, it is important to evaluate the mental health of patients scheduled for elective joint arthroplasty, especially during the ongoing pandemic.11

There are several limitations to this study. First, no record was available of patients invited to reschedule surgery when the hospital resumed elective arthroplasty cases. Thus, these results were based solely on the patients who elected to proceed with surgery. It is unknown how many patients declined surgery and whether their reason was related to the pandemic. Second, current insurance payor was the only tool used to estimate unemployment status. However, those who lost insurance due to unemployment were likely unable to schedule surgery, and could not be accounted for. Third, given the descriptive nature of this study, patient perception on COVID-19 risks, how it influenced their decision to proceed with surgery, or how it has affected their mental health was not collected. Lastly, all procedures were performed at a single community tertiary medical center in Hawai‘i, where the ethnic differences are significant and the rates of positive cases remained relatively low compared to other parts of the country and world. Therefore, the results may not be generalizable to other locations.

Conclusion

The cancelation of hip and knee arthroplasties during the COVID-19 pandemic greatly limited patient access to treatment temporarily. While the risks, individual anxieties, or socioeconomic challenges surrounding elective joint arthroplasty may vary from patient to patient, results of this study showed no outstanding disparities in demographic or pre-operative condition of patients choosing to undergo elective joint arthroplasty prior to and throughout the pandemic. Despite the significant interruption in the delivery of care for patients awaiting elective joint arthroplasty, COVID-19 did not appear to have a significant inequitable effect on the different ethnicities evaluated here, nor did it appear to have significantly changed the demographics of patients seeking elective arthroplasty.

Abbreviations and Acronyms

References