key: cord-0998699-pncvq5aj authors: Stambough, Jeffrey B.; Deen, Justin T.; Walton, Sharon L.; Kerr, Joshua M.; Zarski, Michael J.; Yates, Adolph J.; Andrawis, John P. title: Arthroplasty During COVID-19: Surveillance of AAHKS Members In the First Year of the Pandemic date: 2021-01-09 journal: Arthroplast Today DOI: 10.1016/j.artd.2020.12.029 sha: f1cfeefc08b2cfc33ea40cd96d0981efec4ff1bd doc_id: 998699 cord_uid: pncvq5aj INTRODUCTION: The COVID-19 pandemic has had a severe impact on the practices of adult reconstruction surgeons, primarily due to the elective nature of hip and knee arthroplasty. METHODS: To capture the impact of COVID-19 on its members, the American Association of Hip and Knee Surgeons (AAHKS) sent 6 surveys over a span of seven months from late March until September of 2020 querying its members regarding the effects of COVID on the health and wellbeing of their personal, financial and clinical practice. RESULTS: 92% of surgeons reported a cessation of elective inpatient cases during the height of the crisis. The reduction was greatest for surgeries performed in hospital-based sites of care. 91% reported a drop in clinic volume. At the final surveys, these numbers where 7% and 59%, respectively. In addition, there was a widespread increase in the use of telemedicine during this period. Only a small number of orthopaedic practices permanently closed due to COVID-19; 68% of surgeons, however, sought federal funding to offset their loss of revenue due to the restrictions placed on elective surgeries. Lastly, once elective surgeries were re-instated, the majority of surgeons reported no restrictions with surgical cases and that they believed they were adapting to the challenges of COVID successfully. DISCUSSION: The impact of COVID-19 in 2020 on the practice of arthroplasty resulted in nearly universal loss of volume and significant financial stress. Recovery has been consistent, but incomplete for most practices. Continued monitoring of the members of AAHKS will be needed in 2021 to measure the strength of the demonstrated adaptive recovery of 2020. The widespread SARS-Cov-2 virus and COVID-19 illness in 2020 significantly interrupted the 24 provision of hip and knee arthroplasty in the United States and forced practice alterations while 25 patients and surgeons return to the operating room. On March 11, 2020, the World Health 26 Organization designated the COVID-19 outbreak a pandemic [1] . The COVID-19 pandemic has led to 27 widespread social distancing, sheltering in place, and the closure of multiple workplaces. In late 28 March of 2020, due to concerns over limited healthcare resources, the U.S. Surgeon General, the 29 stopping elective surgeries in the United States [2] [3] [4] . These recommendations were largely based 31 on initial U.S. pandemic modeling. Due to these severe limitations, and the predominantly elective 32 nature of lower extremity arthroplasty, surgeons providing joint reconstruction were especially 33 impacted; surgical volume plummeted, and office-based care was hampered. 34 All health care providers and hospitals were impacted, with some facing imminent insolvency. In 35 response to these challenges the U.S. Congress passed the Coronavirus Aid, Relief, and Economic 36 Security (CARES) Act, a $2.2 trillion bill with $100 billion designated to healthcare including 37 hospitals and providers, as well as $350 billion designated to small businesses, including 38 orthopedic practices [5, 6] . These relief programs have helped to offset some of the financial burden 39 for orthopedic practices, but large financial loses are expected in this fiscal year, with the possibility 40 of more losses moving forward [5] . By the beginning of May 2020, most states had decreased some 41 restrictions on performing elective surgeries. Over the first seven months of the pandemic there 42 were many changes for arthroplasty surgeons. Insight into the impact on adult reconstruction 43 surgeons, their patients, practices and families became a priority of the leadership of the American 44 Association of Hip and Knee Surgeons (AAHKS). In an effort to better understand the effects on its 45 members, AAHKS administered a series of surveys to investigate the specific impact of the COVID-46 19 crisis on its members throughout the country. 47 The American Association of Hip and Knee Surgeons represents over 3,400 American surgeons 50 (500 resident members) whose practices are focused on hip and knee replacement surgeries. Its 51 members provide the majority of the estimated 900,000 total hip and knee replacements 52 performed each year in the US. Because the majority of arthroplasty surgeon's cases are elective 53 and were especially affected by the pandemic and resulting shutdowns, AAHKS conducted email 54 surveys on March 20, 2020 (survey 1), April 3 (survey 2), May 1 (Survey 3), June 5 (Survey 4), 55 August 24 (Survey 5), and September 24 (Survey 6) to assess the evolving effects of COVID-19 on its 56 members. Surveys remained active for 1 week to allow for completion. Members were queried how 57 the COVID-19 pandemic has impacted their personal lives, practice economics, surgical volume, 58 patient care protocols, and attempts to resume normal clinical practices. The questionnaire 59 distributed is provided in Supplementary Figure 1 . The content of each questionnaire was adjusted 60 slightly over the series of surveys as the specialty entered various lockdown periods and the 61 subsequent attempts to recover raised new questions due to heterogenous strategies to rebuild 62 elective volume. 63 The responses were anonymous and reported in aggregate form. Descriptive statistics including 64 mean, standard deviation, and trends were reported for all continuous variables. There was a dramatic reduction of surgeons performing inpatient arthroplasty starting at 82% late 74 March, peaking to 92% early April, and then correcting to a 23% reduction by mid-June ( Figure 1) . 75 By the end of September, however, only 7% of surgeons reported their hospitals still restricted 76 elective surgery. There was a relatively smaller reported reduction in outpatient joint 77 replacements starting at 62%, peaking at 72% and then falling to 12% over the same points in time. 78 At the peak drop in surgeons conducting arthroplasty in early April, ambulatory surgery center 79 (ASC) reduction was less at 44%, in mid-June only 13% and again most recently 1% at the end of 80 September ( Figure 2) . 81 A consistent 75% to 84% of the surgeons reported delaying elective surgeries; an equally 82 consistent 64%-67% of responders shared that patient-driven decisions were a factor delaying 83 surgery. By the beginning of September, no surgeon reported that they were not operating. 86% of 84 surgeons stated that there were no restrictions with performing elective surgeries 85 Clinic volume was universally reported as being reduced; the percentage of responders reporting 86 reductions were over 90% the first three months dropping to 73% mid-June (Figure 3 ), further 87 decreasing to 59% in late September. About two-thirds of responders reported some use of 88 telemedicine early in the pandemic period and by September, 35% were still utilizing telemedicine 89 for clinic visits. The AAHKS members responded in late March that 69% were effectively not working, a number 96 that peaked at 74% in early April and has sharply dropped to 3% in late August. Only a small 97 percentage (approximately 6%-7%) considered the effect of the pandemic on their practice a non-98 Just under half of the surgeons reported consistently over the surveyed time periods that they were 100 feeling financial stress. A sense of being a potential health threat to their family was high in early 101 April at 70% and remained consistent around 45% through the most recent survey. This correlated 102 to the consistent in rate of mental stress reported from 58% at the initial survey but has maintained 103 around 40% over the same time period. 104 105 The reported need to furlough employees rose from 50% in early April, 58% in mid-June to 18% by 107 late September. Over the same time-period, 51-64% of surgeons reported forgoing some amount of 108 compensation. The shutting down of practices peaked at 20% in April and May, but was down to 109 1.5% by the end of September. 110 Applications for support through the CARES Act rose from 46% in April to 67% in June. 111 Reimbursement from at least the first tranche (April 10-17) was received by 52% of members, with 112 6-17 weeks. The average estimated change from normal volume in mid-June was 66% with an 116 average estimated end-of-year return to 89%. However, there were still about 50% of surgeons 117 who reported in September that they were still having to undergo reduced compensation. 118 119 From the May 1 survey, 24% of surgeons reported a roll back of restrictions on elective cases and 121 29% a limited rollback; by mid-June this had risen to 54% and 32% respectively. In the most recent 122 September survey 18% of surgeons stated restrictions still remained in place. Over the same time-123 period, 25% of members had no return to elective cases, which fell to 5% by June. 124 From May to June a response of "no change in surgical indications" rose from 15% to 53%. 125 However, in both surveys, 27% reported limiting surgery to those without COVID risk factors for an 126 adverse course. In May, it was reported that 41% of cases were being limited to same day discharge 127 candidates, which decreased to 21% by mid-June. 128 Preoperative testing for COVID-19 in all pre-operative cases rose from 78% to 88% from survey 3 129 to 6, with the average time of testing before the OR date being three days. Surgeons personally 130 reported a negative COVID test as a requirement before an elective procedure 49% of the time. 131 Routine acceptance of testing was highly accepted by patients at 97%. Requiring pre-operative 132 quarantine, however, has fallen from 40%-43% to 5% from May to June. Currently, testing for 133 providers is occurring in 12% of institutions. 134 Routine use of an N95 mask has fallen from 31% to 14 % while use of a surgical hood has risen 135 from 76% to 82% from May to September. No consistent trends in anesthesia practices were 136 discernable across the times surveyed. surveillance of its membership during this unprecedented pandemic. Its goals are to provide 209 members with benchmarking information, let them know that they are not alone in their efforts to 210 cope, and assure them that their colleagues are there for help and support. 211 • At its peak, 92% of respondents had stopped performing elective inpatient procedures • As many as 74% of respondents reported not working, and 65% reported foregoing some amount of compensation • An estimated 22,500 primary and 2,000 revision Total Joint Replacements were not performed each week of April and May, and a further estimated 10,000 primary and 1,000 revision were not completed each week of June • When comparing sites of care, ASC's showed the least reduction in volume, followed by HOPD and hospital-based surgery, respectively. • Most recently surgeons report returning to approximately 79% of their Pre-COVID volume, with respondents projecting a return to 88% of volume by the end of 2020. • 47% of respondents reported concern their work poses risk to their family, 40% reported mental/emotional stress due to the effects of the pandemic WHO declares COVID-19 a pandemic CMS Adult Elective Surgery and Procedures Recommendations: Limit all 219 non-essential planned surgeries and procedures, including dental, until further notice Surgeon general urges providers to consider stopping all elective surgeries-hospitals 337 AAHKS is seeking your input on how the COVID-19 pandemic is affected your patients and your practice. 338 Please complete the survey below, which should take about five minutes, to give us insight from our 339 members and determine how we can help you. 340 341Thank you for your participation in this survey.