key: cord-0761724-osc7txos
authors: Johnson, Nick R.; Odum, Susan; Lastra, James D.; Fehring, Keith A.; Springer, Bryan D.; Otero, Jesse E.
title: Pain and Anxiety due to the COVID-19 Pandemic. A Survey of Patients with Delayed Elective Hip and Knee Arthroplasty
date: 2021-05-28
journal: Arthroplast Today
DOI: 10.1016/j.artd.2021.05.013
sha: e6a3fcf93f16f5a1dec012fbd8278a888e29aa40
doc_id: 761724
cord_uid: osc7txos

BACKGROUND: The COVID-19 pandemic led to cancellation of all elective surgeries for a time period in the vast majority of the United States. We compiled a questionnaire to determine the physical and mental toll of this delay on elective total joint arthroplasty (TJA) patients. METHODS: All patients whose primary or revision total hip or knee arthroplasty was cancelled due to the COVID-19 pandemic at a large academic-private practice were identified. An11-question survey was administered to these patients via email. All data was de-identified and stored in a REDCAP database. RESULTS: Of 367 total patients identified, 113 responded to the survey. Seventy-seven percent of patients had their surgery postponed at least 5 weeks, and 20% were delayed longer than 12 weeks. Forty-one percent of patients reported an average VAS pain score greater than 7.5. Forty percent of respondents experienced increased anxiety during the delay. Thirty-four percent of patients felt their surgery was not elective. Sixteen percent experienced a fall during the delay, and 1 patient sustained a hip fracture. Level of pain reported was significantly associated with negative emotions, negative effects of delay, and whether patients felt their surgery was indeed elective. 76% reported trust in their surgeon’s judgement regarding appropriate timing of surgery. Communication was listed as the number one way in which patients felt their surgeon could have improved during this time. CONCLUSION: Surgical delay due to the COVID-19 pandemic resulted in increased pain and anxiety many total joint arthroplasty patients. While the majority of patients maintained trust in their surgeon during the delay, methods to improve communication may benefit the patient experience in future delays. LEVEL OF EVIDENCE: Level II

In response to the COVID-19 global pandemic, the Centers for Medicare and Medicaid 24

Services, in conjunction with the White House Task Force, recommended cancellation of all 25 elective surgeries in order to protect vulnerable patients from contracting the virus and to 26 preserve necessary medical personal protective equipment in preparation for a massive influx of 27 COVID-19 into hospitals. 1 It is estimated that, after excluding essential procedures, 30,000 28 primary and 3,000 revision elective total hip and knee arthroplasty (THA and TKA, respectively) 29 were cancelled per week during this time period. 2,3 For patients with arthritis of the hip and 30 knee, this translated into an extended time waiting in pain and reduced function for an unknown 31 period of time. 32

Advanced arthritis of the hip and knee results in significant pain and disability. Total 33 joint arthroplasty consistently provides significant pain relief and allows patients to return to 34 their daily functions with improvements in their preoperative disabilities. 4-6 Determining the 35 optimal timing of surgery is a multifactorial process, but there is evidence that increased 36 preoperative pain level negatively affects recovery, 7 and delays in time to surgery in patients 37 undergoing elective total joint arthroplasty may lead to worse dysfunction and ultimately worse 38 postoperative outcomes. 8, 9 Therefore, pain is a major factor in the complex calculation that takes 39 place when patients and surgeons decide to schedule joint replacement. 40

In the wake of the COVID-19 response, our large academic-private practice cancelled or 41 postponed more than 300 electively scheduled surgeries. Recognizing that patients schedule joint 42 replacement surgery based on pain and disability level at a time that is most convenient, we 43 sought to understand the physical and emotional toll that patients experienced as a result of 44 further delay imposed by the pandemic response. 45 J o u r n a l P r e -p r o o f A concise but thorough survey was administered to patients whose THA and TKA 46 surgeries were cancelled or postponed in response to the viral crisis in order to more fully 47 understand how they were affected by the delay. Further, we sought to explore the relationship 48 between pain level and the experience of negative emotion. We hypothesized that patients would 49 experience progression of pain and negative emotions, which would affect their perception of 50 elective surgery. Finally, we hypothesized that surgeon communication would provide a 51 protective effect on pain level and negative emotion. 52 53

On March 18th, 2020, elective surgeries were stopped in our community due to the 55 COVID-19 pandemic. Surgeries that were deemed to be urgent or emergent, based on surgeon 56 evaluation, were not cancelled. At our Hip and Knee Center within a private academic 57 orthopedic practice, 368 patients were scheduled for elective hip or knee arthroplasty surgery 58 that was ultimately cancelled during an 8-week timeframe due to these changes. An 11-question 59 survey that was designed at our institution that has not yet been externally validated was digitally 60 administered to patients who experienced a delay in their surgery during this time ( Figure 1 ). 61

Questions were formulated to determine the following: length of surgical delay, emotions 62 experienced during waiting period, pain progression, trust in one's surgeon to determine safe 63 timing of surgery, and feelings about communication between surgical team and patient during 64 this time. Patient demographics including gender and age were also collected. Study data were 65 collected and managed using REDCap electronic data capture tools hosted locally at 66

OrthoCarolina Research Institue. 10,11 After review and approval by the Atrium Health 67

Institutional Review Board, the survey was disseminated to patients whose surgery was delayed 68 J o u r n a l P r e -p r o o f Overall, the majority of study patients reported a delay of eight weeks or less. Seventeen 90 (15%) patients reported a delay of 0-4 weeks, 52 (46%) patients reported a 4-8 week delay, 21 91 (19%) patients reported a 9-12 week delay and 23 (20%) patients reported a delay of longer than 92 12 weeks. The median numeric pain score for the study group was 72 (IQR 61, 84). 93

The majority of patients believed that their surgery was elective (64 of 113, 57%). Most 94 patients had increased stress (Table 1) Statistically significant associations were found between patients' reported pain level 102 (Table 2 ) and experience of a negative emotion as well as a negative effect during the delay 103 (p<0.0001). Patients who reported a higher pain level were more likely to feel that their surgery 104 was not elective (p=0.0002). Patients with higher pain levels were more likely to report that they 105 would risk becoming ill from COVID-19 than those with lower pain scores (p=0.0009). We 106 found no statistical difference in patient's undergoing primary versus revision arthroplasty in 107 their negative emotions, thoughts on whether surgery was elective or not, or overall pain rating. 108

We did find that those undergoing THA versus TKA experienced significantly higher numeric 109 pain scores, had a higher chance of reporting that the surgery was not elective, had a higher 110 likelihood of reporting negative effect, and had more pain increase (Table 2 and 3) . Additionally, 111 no statically significant differences were found between patients based on timing of when they 112 answered their questions and when they ultimately underwent surgery. No statistically significant 113 J o u r n a l P r e -p r o o f associations were found between duration of reported surgical delay (Table 4) sought to understand the emotional and physical toll that patients experienced following delay of 123 their total joint replacement. Although TJA is categorized as elective, patients experience 124 significant pain and disability due to arthritic joints and often delay surgery as long as possible. 125

With this in mind, further delay may be a significant source of progression of pain and disability, 126 affecting patients' perception regarding the elective nature of their scheduled surgery. Indeed, we 127 found that during the delay, one-third of patients did not feel their surgery should be categorized 128 as elective. 129

We found anxiety to be prevalent in our cohort. Patients with arthritis have high levels of 130 anxiety at baseline, [13] [14] [15] [16] which can be associated with worse outcomes following arthroplasty. One of the most profound findings of the current study is the significant association 150 between pain level reported and negative emotions, effects, and perception of elective surgery. 151 Furthermore, patients who reported a higher level of pain were significantly more likely to report 152 an increase in pain over the waiting period. Patients with higher pain levels were also more likely 153 to report willingness to risk COVID contraction and ultimately, were more likely to have 154 undergone surgery at the time of this analysis. 155 Importantly, our results elucidated the strength of the patient-surgeon relationship. Nearly 156 99% of patients did not feel any frustration with their surgeon personally. Additionally, 76% of 157 patients trusted their surgeon to make the right choice regarding delay and timing of surgery. 158

Although this is a good majority, it does bring into question why 24% of patients did not trust 159 their surgeons. It is unclear why this amount did not trust their surgeons to make the right 160 decision. It could be theorized that due the general lack of consensus on COVID-19 and how to 161 combat the virus led to a distrust in some people towards healthcare professionals in general. It 162 also could be due to the general distrust some patients have in healthcare as a whole due to 163 changes in delivery and presumed lack of transparency. Axelrod et. al 23 The reported results should be interpreted in light of several study limitations. First, there 180 was a response rate of 32%. However, this rate is consistent with many web-based surveys in the 181 medical literature, which consistently achieve less than a 50% response rate 28,29 . Regardless of 182 cause, this response rate could introduce a response bias that creates difficulty in accurately 183 assessing these results. However, there is little concern that this would affect the overall validity 184 of our data or our ultimate conclusions because the goal of current study was designed to be a 185 descriptive study to report on patient emotions experienced during delay, not prove that certain 186 cohorts of patients experienced stronger negative emotions than others. 187

The American College of Surgeons defines elective surgery as any procedure that, if 188 delayed longer than 4 weeks, would not cause harm to the patient and ultimately worsen their 189 outcome. 30 More than one-third of patients in our study felt that TJA should not be categorized 190 as elective, and indeed, greater than 75% of patients reported a negative effect of the delay. The term "elective" means that a surgery is not urgent and can be safely postponed. In your opinion, is your surgery an "elective" procedure?

Yes, my surgery is elective. No, it is not elective.

Not Sure.

How long was your surgery postponed? 1-2 Weeks 3-4 Weeks 5-6 Weeks 7-8 Weeks 9-10 Weeks 11-12 Weeks Longer Than 12 Weeks Check All That Apply 

AOS Guidelines for Elective Surgery During the COVID-19

Effect of COVID-19 on Hip and Knee Arthroplasty 219

Surgical Volume in the United States

Resuming Elective Orthopaedic Surgery During 222 the COVID-19 Pandemic: Guidelines Developed by the International Consensus Group 223 (ICM)

A comparison of outcomes in osteoarthritis 225 patients undergoing total hip and knee replacement surgery

CMS Releases Recommendations on Adult Elective Surgeries

Dental Procedures During COVID-19 Response | CMS

elective-surgeries-non-essential-medical-surgical-and-dental

Mental disorders in a population sample with 253 musculoskeletal disorders

Health-related quality of life in patients waiting 256 for major joint replacement. A comparison between patients and population controls

Self-perceived distress and self-perceived functional recovery 259 after recent total hip and knee arthroplasty

Depression in rheumatoid arthritis: A 262 systematic review of the literature with meta-analysis

Predictors of Pain Catastrophizing, Anxiety, and Depression in Patients Undergoing Total 266

Risk Factors for Moderate 269 and Severe Persistent Pain in Patients Undergoing Total Knee and Hip Arthroplasty: A 270

The unhappy total knee arthroplasty 272 (TKA) patient: Higher WOMAC and lower KSS in depressed patients prior

Impact of Psychological Distress on Pain and Function Following 276

Electively Scheduled Hip and Knee Arthroplasty Patients in the United States

Decline in Health-Related Quality of Life 281 reported by more than half of those waiting for joint replacement surgery: A prospective 282 cohort study

Maintaining trust in the surgeon-patient relationship: Challenges 284 for the new millennium

Automated Mobile Phone Messaging in Total Joint Arthroplasty

Does Patient Experience After a Total Knee Arthroplasty Predict 289

After-Hours Calls in a Joint 291

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

Question 7During your surgical delay, which of the following did you experience? Check all that apply