Patient Perception Regarding the Safety of Elective Joint Arthroplasty Surgery During the COVID-19 Pandemic

The impact of elective surgery restrictions during the COVID-19 (coronavirus disease 2019) pandemic on shoulder and elbow surgery: patient perceptions

BACKGROUND

In late 2019 and early 2020, a novel coronavirus, COVID-19 (coronavirus disease 2019), spread across the world, creating a global pandemic. In the state of Pennsylvania, non-emergent, elective operations were temporarily delayed from proceeding with the normal standard of care. The primary purpose of this study was to determine the proportion of patients who required prescription pain medication during the surgical delay. Secondarily, we sought to determine the proportion of patients who perceived their surgical procedure as non-elective and to evaluate how symptoms were managed during the delay.

MATERIALS AND METHODS

A single institutional database was used to retrospectively identify all shoulder and elbow surgical procedures scheduled between March 13 and May 6, 2020. Charts were manually reviewed. Patients who underwent non-shoulder and elbow-related procedures and patients treated by surgeons outside of Pennsylvania were excluded. Patients whose surgical procedures were postponed or canceled were administered a survey evaluating how symptoms were managed and perceptions regarding the delay. Preoperative functional scores were collected. Statistical analysis was performed to determine associations between procedure status, preoperative functional scores, perception of surgery, and requirement for prescription pain medication.

RESULTS

A total of 338 patients were scheduled to undergo shoulder and elbow surgery in our practice in Pennsylvania. Surgery was performed as initially scheduled in 89 of these patients (26.3%), whereas surgery was postponed in 179 (71.9%) and canceled in 70 (28.1%). The average delay in surgery was 86.7 days (range, 13-299 days). Responses to the survey were received from 176 patients (70.7%) in whom surgery was postponed or canceled. During the delay, 39 patients (22.2%) required prescription pain medication. The surgical procedure was considered elective in nature by 73 patients (41%). One hundred thirty-seven patients (78%) would have moved forward with surgery if performed safely under appropriate medical guidelines. Lower preoperative American Shoulder and Elbow Surgeons scores (r = -0.36, P < .001) and Single Assessment Numeric Evaluation scores (r = -0.26, P = .016) and higher preoperative visual analog scale scores (r = 0.28, P = .009) were correlated with requiring prescription pain medication. Higher preoperative American Shoulder and Elbow Surgeons scores were positively correlated with perception of surgery as elective (r = 0.4, P < .001).

CONCLUSION

Patients undergoing elective shoulder and elbow surgical procedures during the COVID-19 (coronavirus disease 2019) pandemic experienced a delay of nearly 3 months on average. Fewer than half of patients perceived their surgical procedures as elective procedures. Nearly one-quarter of patients surveyed required extra prescription pain medicine during the delay. This study elucidates the fact that although orthopedic shoulder and elbow surgery is generally considered "elective," it is more important to a majority of patients. These findings may also be applicable to future potential mandated surgical care delays by other third-party organizations.

Keeping the Lights On: The Impact of the COVID-19 Pandemic on Elective Total Joint Arthroplasty Utilization in the United States

Background

It was estimated that up to 30,000 primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures would be cancelled each week during the moratorium on elective surgeries in the United States. The purpose of this study was to analyze the impact of the COVID-19 pandemic on elective total joint arthroplasty utilization in the United States.

Methods

A retrospective study was conducted using the PearlDiver database. Patients who underwent primary elective THAs and TKAs were identified and filtered by state and month from January through September of both 2019 and 2020. The volume of these procedures immediately following the moratorium on elective surgeries was compared to that of the same months the previous year.

Results

For THA, overall, there was a 27.39% reduction in volume from 2019 to 2020 in March and an 88.94% reduction in April. For TKA, overall, there was a 31.28% reduction in volume in March and a 96.61% reduction in April. When the states were separated into 2 cohorts by the 2020 presidential election vote, there was a significantly larger decrease in THA and TKA volume observed in the 25 states and Washington DC that voted democrat than that in the 25 states that voted republican in both March (P < .05) and April (P < .05). Both THA (118.29%) and TKA (101.02%) volume returned to prepandemic levels by June.

Conclusions

Overall, this study demonstrated that elective total joint arthroplasty utilization did reduce as anticipated following the CMS moratorium on elective surgeries but quickly returned to prepandemic levels by June.

Level of Evidence

Level III.

The Effect of COVID-19 on Elective Total Knee Arthroplasty Utilization, Patient Comorbidity Burden, and Complications in the United States: A Nationwide Analysis

INTRODUCTION

Total knee arthroplasty (TKA) is one of the highest volume elective procedures done nationwide. Elective surgery was suspended because of the COVID-19 pandemic. The utilization trends, comparison of patient demographics, and postoperative outcomes in 2020 have yet to be evaluated substantially. We compared temporal trends in procedural volume, patient demographics, and postoperative complications of elective TKA in 2019 and 2020.

METHODS

Using a multicenter, nationwide representative sample, a retrospective query of the 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was conducted for patients undergoing elective TKA. Temporal trends in utilization, demographics, and length of stay were compared pre-COVID-19 (2019 to 2020Q1) with post-COVID-19 (2020Q2 to Q4). Postoperative outcomes were compared by calendar year (2019 versus 2020). Linear regression was used to evaluate changes in procedural volume over time. A significance threshold of P < 0.05 was used.

RESULTS

A total of 121,415 patients underwent elective TKA in 2019 (N = 72,002) and 2020 (N = 49,413), a 31.4% decline. The proportion of hospital-defined "outpatient" TKAs in 2020 was significantly greater than that in 2019 (41.5% versus 25.5%; P < 0.001). Elective TKA utilization declined by 65.1% in 2020Q2 and never returned to prepandemic baseline in 2020Q3 to Q4. The average length of stay was shorter in 2020 (1.56 versus 1.87 days; P < 0.001). The proportion of same-day discharge increased each quarter from 2019Q1 to Q4 (6.2% to 8.6%) to 2020Q1 to Q4 (8.7% to 17.1%). Total complication rates were similar in 2019 (4.84%) versus 2020 (4.75%); P = 0.430. The 30-day mortality (0.08% versus 0.07%; P = 0.858), revision surgery (1.0% versus 1.0%; P = 0.940), and readmission (2.8% versus 2.6%; P = 0.053) rates were no different between 2019 and 2020.

CONCLUSION

Elective TKA declined during the second quarter of 2020. A large proportion of surgeries were transitioned to outpatient with rates of same-day discharge increasing over the study period, despite no change in complication, mortality, and readmission rates. Patient outcomes were not compromised despite pandemic restrictions for elective surgery.

LEVEL OF EVIDENCE

Level III.

Telemedicine Hip and Knee Arthroplasty Experience During COVID-19

BACKGROUND

Although telemedicine visits were essential and adopted by providers and patients alike, few studies have been conducted evaluating orthopedic patient perception of the care delivered during these visits. To our knowledge, no study has evaluated specific factors that affected patient satisfaction with telemedicine and the receptiveness to continue virtual visits post COVID-19 in total joint arthroplasty (TJA) patients. Thus, the purposes of our study are to determine the following: (1) patient satisfaction with using TJA telemedicine services, (2) whether patient characteristics might be associated with satisfaction, and (3) whether virtual clinic visits may be used post-COVID-19.

METHODS

A prospective, cross-sectional survey study was completed by 126 TJA patients who participated in telemedicine visits with TJA surgeons from May 1, 2020 to August 31, 2020. The survey consisted of questions regarding demographics, satisfaction, and telemedicine experiences.

RESULTS

One hundred one (80.2%) patients were satisfied with their telemedicine visit, with patients <80 years old (P = .008) and those with a longer commute time (P = .01) being more satisfied P = .01. There was a significant preference for in-person visits when meeting arthroplasty surgeons for the first time (P < .001), but patients were equally amenable to follow-up telemedicine visits once there was an established relationship with the surgeon.

CONCLUSION

Younger patients, patients with longer commute distances, and patients who had established relationships with their provider expressed higher satisfaction with telemedicine arthroplasty visits. Although >80% of patients were satisfied with their telemedicine visit, an established patient-provider relationship may be integral to the success of an arthroplasty telemedicine practice.

Elective Inpatient Total Joint Arthroplasty Case Volume in the United States in 2020: Effects of the COVID-19 Pandemic

BACKGROUND

Despite known surgical volume reductions in 2020 during the height of the COVID-19 pandemic, no study has fully quantified the impact of the pandemic on the number of elective inpatient total hip (THA) and total knee arthroplasty (TKA) cases. The purpose of the present study was to analyze THA and TKA case volumes in the United States during the COVID-19 pandemic.

METHODS

The Premier Healthcare Database was utilized to identify adults undergoing primary elective THA or TKA from January 2017 to December 2020. The National Inpatient Sample was cross-referenced to provide nationwide representative sampling weights. Patients undergoing revision total joint arthroplasty (TJA) or non-elective surgery were excluded. Two quantitative models were created from both databases to estimate TJA case volume in 2020. Descriptive statistics were utilized to report monthly changes in elective TJA utilization throughout 2020. Univariate analyses were performed to compare differences between subgroups.

RESULTS

From 2017 to 2019, it was estimated that 1,006,000 elective inpatient TJAs (64.2% TKA and 35.8% THA) were performed annually. In 2020, an estimated 526,000 to 538,000 cases (62.0% TKA and 38.0% THA) were performed, representing a 46.5% to 47.7% decrease in nationwide volume from the prior 3-year average. Moreover, the elective TJA case volume for April 2020 was 1.9% of the average for that month from 2017 through 2019. Subsequently, case volumes for May and June increased compared with the volumes for those months from 2017 through 2019. There was then a decrease in cases for July, corresponding with the "second wave" of COVID-19, followed by an additional steady monthly decline through December, corresponding with the "third wave." Finally, the elective TJA cases for December 2020 represented only 41.0% of the average case volume for that month from 2017 through 2019.

CONCLUSIONS

In the midst of the 2020 COVID-19 pandemic, approximately 526,000 to 538,000 elective inpatient TJA cases were performed, representing a 46.5% to 47.7% decrease compared with the 3 previous years. The effects of the COVID-19 pandemic persisted through the end of that year, with decreased case volume through December 2020.

How Do Orthopaedic Patients Prefer to Be Contacted During a Pandemic?

Introduction

Communication with patients is a vital part of the surgical pathway, and when done effectively, it can greatly improve patient outcomes and patient satisfaction and reduce canceled appointments. Different forms of communication work well for different patient demographics, and it is important to optimize communication techniques. We designed a study to review the communication preferences of orthopedic patients during the COVID-19 pandemic.

Methods

A cross-sectional study was performed by asking patients who were due to undergo orthopedic procedures to answer a questionnaire on their communication preferences, the reminder notice period for appointments, and safety and satisfaction ratings during the COVID-19 pandemic.

Results

Communication method preferences are influenced by patient factors such as gender and age. Phone calls were the most popular communication method throughout all patient groups, with 61% selecting it as their preference. Younger patients preferred multiple communication methods of phone calls, texts, and emails, whereas the older group had a stronger preference for letters. Letters were more popular among females (28% compared to 10% of males), whereas males had a stronger preference for other communication methods. The majority of patients said they would not have liked a letter prior to their clinic appointment (65%). Of those who indicated a preferred notice period, 73% would have liked five days or less notice prior to their clinic appointment, while 65% would have liked 10-14 days notice prior to their surgery. The average safety rating was 55%. The overall satisfaction rating with the communication process was 71.7%.

Conclusion

The COVID-19 pandemic has changed patient feelings towards healthcare and, as a result, changed the way healthcare is delivered. Communication method preferences among trauma and orthopedic patients vary and depend on factors such as gender and age. If healthcare departments can optimize their communication processes, they will improve their patient outcomes and enhance their resources.