key: cord-0989295-7a80jff2 authors: Brown, Timothy S.; Bedard, Nicholas A.; Rojas, Edward O.; Anthony, Christopher A.; Schwarzkopf, Ran; Lowry Barnes, C.; Stambough, Jeffrey B.; Mears, Simon C.; Edwards, Paul K.; Nandi, Sumon; Prieto, Herman; Parvizi, Javad title: The Effect of The COVID-19 Pandemic On Electively Scheduled HIP and KNEE Arthroplasty Patients in THE United States date: 2020-04-22 journal: J Arthroplasty DOI: 10.1016/j.arth.2020.04.052 sha: 938e76bbd7e2ed1ce9e5e9c9a634b998294c8833 doc_id: 989295 cord_uid: 7a80jff2 Abstract In response to the COVID-19 pandemic, US hospitals stopped performing elective procedures. This led to cancellation of a large number of hip and knee arthroplasty cases. We aimed to assess the effect this had on our elective primary arthroplasty patients by distributing a specifically designed survey to patients across six institutions identified through the AAHKS Research Committee. Surveys were completed by 360 patients over the course of one week. Patients were most anxious about the uncertainty of when their operation could be rescheduled. Although 85% of patients understood and agreed with the cancellation of elective surgeries as part of public health measures to curb the spread of pandemic, almost 90% of patients plan to reschedule as soon as possible. Financial concerns were minimal in this cohort. Patients suffering from pain of hip and knee arthritis continue to struggle with their end-stage disease and despite anxiety about the COVID-19 pandemic, plan to undergo arthroplasty as soon as possible. The 2020 global pandemic caused by the novel coronavirus SARS-CoV-2 (COVID-19) 23 [1] has had drastic effects across world economies and healthcare systems [2, 3] . With the rapid 24 spread across the globe, many regions were overwhelmed with patients requiring respiratory 25 support [4] [5] [6] . Public health interventions in China provided guidance for other regions in the 26 world on how to face a looming worldwide crisis [7] . After the first identified infection in the 27 United States (US) in late January 2020 and subsequent evidence of community spread, state 28 governments began drastically limiting businesses and issuing stay at home orders. Hospitals 29 began limiting elective surgical procedures following national health guidelines in an effort to: 1) 30 slow the spread of the disease, 2) protect patients and staff from asymptomatic or undiagnosed 31 carriers, 3) conserve personal protective equipment (PPE), and 4) reserve inpatient capacity for 32 the COVID-19 infections [8, 9] . With the World Health Organization (WHO) declaration of a 33 global pandemic on March 11, 2020, elective cases in the US, including hip and knee 34 arthroplasty, began to be postponed indefinitely or canceled outright. The US Surgeon General 35 recommended stopping elective surgery on March 14, 2020. 36 Hip and knee arthroplasty are two of the most commonly performed elective procedures 37 in the US, with approximately 1.5 million procedures performed annually [10, 11] . Thousands 38 of patients suffering from the daily pain of arthritis were affected and the true impact of the 39 pandemic on these patients is unmeasured. The American Association of Hip and Knee Surgeons 40 (AAHKS) sought to understand the impact these postponements have had on our patient 41 population. The anxiety induced by the pandemic is well-documented amongst healthcare 42 workers [12], but poorly understood amongst patients. The aim of the current study was to 43 identify hip and knee arthroplasty patients across many different institutions in the United States 44 that had their scheduled primary joint replacement postponed or canceled due to the COVID-19 pandemic guidelines for elective surgery, and assess their pain, anxiety, physical function, and 46 economic ability to undergo a delayed operation once the threat of COVID-19 has subsided. 47 48 We administered a novel questionnaire to our elective hip and knee patients affected by 50 the COVID-19 pandemic. Participating centers were identified through the AAHKS Research 51 Committee and Research Consortium. Six centers participated in the study. These institutions 52 represent both academic and private medical centers in varied regions throughout the US (Table 53 1). Each institution submitted and obtained local IRB approval or exemption for the study, and 54 all sites signed a standardized data use and transfer agreement with the host institution 55 (University of Iowa). 56 Inclusion criteria for the study were patients scheduled for primary elective hip or knee 57 arthroplasty in the Spring of 2020 who had their surgery postponed or canceled due to the 58 COVID-19 pandemic. No protected health information (PHI) was collected from any patient. 59 The survey ( reported as mean ± standard deviation. For the 5 questions that addressed anxiety around 68 COVID-19, responses from the Likert scale were analyzed as categorical responses and also 69 turned to a continuous variable with mean presented (1 = no anxiety to 5 = severe anxiety). 70 Univariate analyses were performed with age (less that 65 years versus 65 years and older) and 71 with U.S. geographic region (Midwest, Northeast, South). We used Chi-square to detect the 72 relationship between age and region group for each of the categorical variables. Wilcoxon Sum 73 Rank Test or Kruskal-Wallis Test were used to compare the differences for continuous variables 74 among these same groups. All statistical analysis was performed using SAS 9.4 (SAS Inc., Cary, 75 NC, USA) with significance level at p < 0.05. Overall, not knowing when the canceled joint replacement will be rescheduled was rated 91 as the highest source of anxiety (3.4 ± 1.4). Not knowing when the procedure will be rescheduled 92 caused moderate or severe anxiety in 217 patients (60%). Becoming infected with COVID-19 93 (3.0 ± 1.3) and spreading infection to others (3.1 ± 1.4) were also high causes for anxiety. 94 Patients were least concerned with finances (2.3 ± 1.3) and job security/disability (1.8 ± 1.2). 95 There were significant differences in the responses by both age and region (Tables 2 and 96 3 The majority of patients stated that their pain from hip/knee arthritis has increased since 103 surgery cancellation (54%), and 30% stated that they would have proceeded with surgery in spite 104 of the risks posed by COVID-19. Activity levels have decreased for 50% of the participants since 105 cancellation. While the majority of patients have help at home assisting with activities of daily 106 living, 15% of the respondents were without help at home and 21% of patients felt isolated or 107 lonely as a result. There were no significant differences between age groups or regions. 108 109 Patients varied in responses to further efforts to curb the spread of COVID-19. The 111 majority of patients (85%) agreed with the decision to stop elective procedures in the face of 112 ongoing pandemic. There were no differences in age or region for these responses. 113 When asked about future plans for arthritis treatment, 316 patients (88%) stated they will 116 reschedule surgery in the near future. Only 23 patients (6%) wished to delay further for fear of 117 COVID-19, 5 patients (1%) wished to delay for financial reasons, 3 patients (1%) in order to 118 accrue more paid time off. There were no differences in age or regional responses. The broad recommendation to postpone elective operations in the United States during the 127 pandemic has led to a large cohort of patients with end-stage hip and knee arthritis that can no 128 longer receive their recommended surgical treatment. By some estimations, as many as 150,000 129 patients will have their elective hip/knee arthroplasty postponed per month while the elective 130 moratorium lasts [10] . In this study, we aimed to focus on these patients and their responses to the 131 anxiety caused by COVID-19, their daily disease burden from lower extremity arthritis, and their 132 future focus for rescheduling the planned procedure. 133 We found that most patients had their operation postponed by their surgeon, although 134 patients from regions harder hit by the pandemic were more likely to have canceled their own 135 surgery (18% cancellation in Northeast urban areas compared to 3% for the rural Midwest). The present study is limited by its small number of patient responses relative to the 146 predicted number of canceled cases and the homogeneity of the participating sites. Continued 147 work will occur over the next few months to distribute the survey more broadly and to further 148 understand the effect the COVID-19 pandemic has had on our patients. With more patients, we 149 hope to validate this initial study and perform more in-depth subgroup analyses. A second 150 limitation includes the fact that survey administration was mixed between online completion and 151 telephone review of the questions by a member of the surgeon's team. It is possible that the 152 discrepancies in administration techniques could bias patient responses. 153 154 The COVID-19 pandemic has had a dramatic effect on everyday life in the United States and the 156 rest of the world, and has affected hip and knee surgeons, their practices, and most importantly 157 our patients. From the present study, we conclude that patients clearly have anxiety related to the 158 COVID-19 pandemic and continue to suffer from the effects of lower extremity arthritis while at 159 home. Stark regional differences exist in the burden of COVID-19 in the US and this is seen in 160 our patient's responses. Patient age also plays a large role in the reaction to the pandemic, 161 particularly in regards to financial and job security concerns. This pilot study will be expanded to 162 include all regions of the country and larger numbers of patients in the ensuing weeks before 163 arthroplasty surgeons resume the performance of elective joint replacement surgery. Record ID When was your surgery originally planned? March April May June or later Was your planned surgery postponed or canceled by My surgeon postponed or canceled the operation your surgeon/hospital or did you cancel the surgery? I chose to postpone or cancel the operation out of concern for COVID-19 3. Please rate each item with the following scale (severe anxiety, moderate anxiety, neutral, minimal anxiety, no anxiety). A Novel Coronavirus from Patients with Pneumonia in China Responding to Covid-19 -A Once-in-a-Century Pandemic? Covid-19 -Navigating the Uncharted Critical Care Utilization for the COVID-19 Outbreak in 176 Early Experience and Forecast During an Emergency Response Clinical Characteristics of Coronavirus Disease 2019 in China Covid-19 in South Korea -Challenges of 185 Subclinical Manifestations Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in 188 The COVID-19 Pandemic in the US: A Clinical Update US Emergency Legal Responses to Novel Coronavirus: Balancing 192 Public Health and Civil Liberties Impact of the economic downturn on total joint 194 replacement demand in the United States: updated projections to 2021 Projected Volume of Primary Total Joint Arthroplasty in 197 the Understanding and Addressing Sources of Anxiety Among 200 Health Care Professionals During the COVID-19 Pandemic A Technique for the Measurement of Attitudes COVID-19): Cases in *One survey was completed from a seventh institution and was counted in the frequency but not in the analysis. *One survey was completed from a seventh institution and was counted in the frequency but not in the analysis.