Title: Elective Orthopedic Surgery and COVID-19: An Examination of the Pandemic’s Effects on Total Knee Arthroplasty Backlog and Patient Impact
Authors: Campbell Addington, OMS1; Michelle Bowers, OMS1; Ethan Daffner, OMS1; Austin Evanovich, OMS1
Introduction
The COVID-19 pandemic disrupted all aspects of society with a particularly pronounced impact in the healthcare sector, producing profound delays in surgical scheduling and treatment that continue to have lasting ramifications. As society adjusts to the ‘new normal’ of living in a pandemic, the importance of exploring the impact of delays in elective surgery increases. This narrative review examines the impact of the COVID-19 pandemic on elective total knee arthroplasty (TKA) backlog and patients.
Methods
We created rigorous inclusion and exclusion advanced search criteria applied to four major research databases: PubMed, CINAHL, TripPro, and Cochrane Library. Our inclusion words were ‘COVID’ OR ‘Coronavirus’ OR ‘SARS-COV-2’ AND ‘Total Knee Arthroplasty’ OR ‘knee replacement’ AND ‘Delay’ OR ‘Backlog.’ We included articles published in 2020 and 2021 to selectively highlight the COVID-19 pandemic. The 54 total articles produced (PubMed= 19, CINAHL=1, TripPro=32, Cochrane Library=2) were then read and evaluated through our exclusion criteria. The focuses of the remaining 13 articles divided well into two categories: the volume of TKA backlog with corresponding projections and the impact of delay on patient outcomes.
Results
The height of the pandemic saw cancellation of all elective surgical procedures, resulting in immediate and long-lasting impact on future surgical caseloads. Our research uncovered several studies that projected multi-year delays in resolving this burden. Patients with delayed surgery reported increased pain, associated with increased use of opioids and other pain medication. Multiple studies correlated delays in surgery with increased patient anxiety. Delays were associated with worse surgical outcomes, particularly in the context of pandemic-related recovery restrictions. One study suggested a tiered approach to resuming surgery, prioritizing patients from disproportionately affected communities and those who would receive the most benefit.
Discussion
Addressing the growing TKA backlog, reviewed studies proposed guidelines for safe patient return using an ethical framework and discussed best surgical practices for minimizing surgical revisions and repeat patient appearances. This review identified common causes of patient pain, anxiety, and clinical deterioration and means to mitigate these outcomes through improved physician-patient communication and effective alternative therapies. As the healthcare sector looks to establish a ‘new normal’ during the next phase of the COVID-19 pandemic, it must tackle the growing backlog of surgeries and its consequences on patients. Society may feel the effects of COVID-19 for years, necessitating our timely adaptation in surgical practice and medical care delivery to ensure patients remain stress-free, informed, and healthy.
Thanks for presenting about this interesting topic! As a judge for this project, I was wondering if you could explain the left graph on the first results slide more. I also was wondering about what the left table on the next slide was showing – e.g. are patients not significantly concerned about becoming infected with COVID 19? Thanks!
Hi Dr. Rhodes, thank you for your questions. The first graphic was adapted from Wilson et al’s paper, “Quantifying Backlog of Total Hip and Knee Arthroplasty”. The authors of this paper used pre-pandemic caseloads and existing trends to project expected monthly surgical volume for the year 2020. They then modeled the impact of a complete shutdown of elective surgery, lasting anywhere from 1-3 months (the “through April” etc. axes on the graph), adding these totals to the expected monthly volume projection. Next, they calculated how long it would take to compensate for the volume overload at a) the current average caseload, 100% (blue) and b) at 120% of normal volume (green). For a more thorough description of their modeling and data, please reference the results and discussion section of their paper.
In regards to your second question, the table referenced from, “The Effect of the COVID-19 Pandemic on Hip and Knee Arthroplasty Patients in the United States,” implies that the patients surveyed under 65 years old reported higher levels of anxiety regarding the ‘Unknown length of surgical delay’ rather than a lack of anxiety regarding ‘Becoming infected with COVID-19′. It should be noted that this survey was distributed to 2315 patients at 15 surgical centers, of which only 848 patients responded. This could imply response bias in that the patients most frustrated with the surgical delay would be most likely to respond. We again would recommend the sourced research for a more in-depth discussion of the authors’ findings. Additionally, it is worth mentioning that this figure is a single example of our findings, and similar conclusions were found in several other papers that met our inclusion criteria. These studies were omitted from our presentation due to time constraints, however, we would be more than willing to share our resources with you if you are interested. Thank you again!
Thank you for a great presentation. As a judge for this project, I am curious about some of the suggestions for dealing with the surgical backlog. Increasing surgeries by 120%, offering more therapies, and increasing physician communication were all listed as possibilities. Any thoughts on how this could be accomplished given the decrease is numbers of medical care providers and support staff?
Hi Dr. Habecker,
Thanks for taking the time to view our presentation! We do have some thoughts on how to decrease the surgical backlog. We must mention that the scope of our reviewed data did not directly address these challenges in the face of a provider or support staff shortage; however, our impression of the reviewed data and discussion is as follows:
Prior to scaling up surgical workload to 120%, we must get back to 100%. In our first discussion slide, we mentioned establishing ethical guidelines, as suggested by Humbyrd et al, for returning patients to surgery. In other words, evaluating and prioritizing the waitlisted patients to determine who returns first. We believe these guidelines would allow the most at-risk patients to receive surgery first and from there, proceed down the list to the least emergent cases. If surgery centers and hospitals can return to 100% volume, maintain high levels of surgery safety and resulting patient quality of life, as well as minimize risks of coronavirus infection, this allows for potential scaling up to 120% workload.
Another suggestion we mentioned involved bridging the patient to surgery with effective alternative therapies. These therapies must address increased patient anxiety, depression, and pain because of a surgical delay. We believe that hospitals and surgery centers may benefit from contracting or coordinating with third party mental health resources and physical therapy centers. This would focus limited medical resources and personnel towards providing the surgeries themselves, enabling them to maintain a high volume, more efficiently maneuvering the expansive backlog of surgeries. Additionally, surgeons may also be able to communicate updates with patients via Telehealth. These brief visits should help alleviate some of the uncertainty the patient may be experiencing following their delay in surgery. As discussed in our review, if patients can remain free from stress, anxiety, or depression, they are more likely to have better clinical outcomes following surgery.
We believe that implementing these suggestions may alleviate the burden on the limited medical and surgical staff, allocating patient needs to others more suited to managing problems such as pain, depression, and anxiety prior to surgery. As a result of this, the surgical staff will be able to focus their time and energy on tackling the backlog, helping return the caseloads to pre-COVID levels and enabling the patients to receive the help they need. More research should be done to study the efficacy of these suggestions and explore other potential options to help patients.
Thanks again, Dr. Habecker!
Thanks for presenting this interesting work. As a judge I have a few questions. My first question is how did you all account for studies conducted prior to Covid? In the presentation you list your inclusion criteria as papers published after 2020. However, it can often times take several months for manuscript to be published in our search some of the data could’ve been collected before the pandemic began. My second question has to do with your focus on the patient experience. Your methods and search keywords used seem to focus on finding literature related to the backlog of procedures versus literature related to the patient experience. Did you all conduct a separate, second search with separate key words related to the patient experience? How are the surveys chosen that you decided to review? Thanks!
Hi Dr. Fritz, thank you for your interest. In regards to your first question, the inclusion term “Coronavirus” was insufficient to limit our results, as it did include pre-pandemic research, but was necessary in order to capture all research pertaining to the evolving COVID-19 pandemic and terminology referencing it. In an attempt to focus our review scope, our exclusion criteria eliminated publications from before 2020 as data published before this would inherently not be relevant to our topic. The delay between data collection and publication did limit our paper in that we were unable to review current and likely relevant information that has yet to be published. This is an area of future research that could be addressed.
When we began our research, we wanted to see the overlap between elective total knee arthroplasty and the disruptions caused by the COVID-19 pandemic. We established inclusion and exclusion criteria that we thought best highlighted this overlap in the appropriate timeframe. After sifting through the populated articles, the thirteen articles fitting both criteria were grouped based on common themes we identified, such as “surgical backlog” and “patient experience.” Most articles focusing on patient experience included patient surveys in their study. We felt that these surveys appropriately highlighted impacts on patients experiencing delays in their surgical care; thus, we thought conducting a second literature search with separate keywords was unnecessary. The surveys that we described in our abstract and presentation were sampled from the articles meeting our inclusion and exclusion criteria and effectively highlighted patients’ feelings regarding their surgical delays. Further targeted research into patient experience may be warranted but fell outside the scope of this research project.