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Total Joint Arthroplasty Patient Demographics Before and after COVID-19 Elective Surgery Restrictions

  • Morgan McCoy
    Affiliations
    Louisiana State University Health Sciences Center (LSUHSC) Department of Orthopaedic Surgery, 1542 Tulane Avenue, Box T6-7, New Orleans LA 70112, United States
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  • Natalie Touchet
    Affiliations
    Louisiana State University Health Sciences Center (LSUHSC) Department of Orthopaedic Surgery, 1542 Tulane Avenue, Box T6-7, New Orleans LA 70112, United States
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  • Andrew G. Chapple
    Affiliations
    Louisiana State University Health Sciences Center (LSUHSC) Department of Orthopaedic Surgery, 1542 Tulane Avenue, Box T6-7, New Orleans LA 70112, United States
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  • Anna Cohen-Rosenblum
    Correspondence
    Corresponding author: Anna Cohen-Rosenblum, MD . Address: LSUHSC Department of Orthopaedic Surgery, 1542 Tulane Avenue, Box T6-7, New Orleans LA 70112 Phone: +1-504-903-9420
    Affiliations
    Louisiana State University Health Sciences Center (LSUHSC) Department of Orthopaedic Surgery, 1542 Tulane Avenue, Box T6-7, New Orleans LA 70112, United States
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Open AccessPublished:January 01, 2023DOI:https://doi.org/10.1016/j.artd.2022.101081

      Highlights

      • Post-COVID restrictions, THAs were performed at a higher proportion than TKAs
      • Patients in the post-COVID era were more likely to be Medicaid enrollees
      • No difference in sex, race, BMI, smoking status, or age between groups
      • Ours is of very few studies to analyze post-COVID demographics on a regional scale
      • Length of stay was significantly shorter in the post-COVID era

      Abstract

      Background

      In 2020, the COVID-19 pandemic caused cessation of non-emergent total joint arthroplasty (TJA, referring to total hip and total knee arthroplasty) operations between mid-March and April 2020. The purpose of this study is to analyze effects and potential disparities in access to care due to the COVID-19 restrictions.

      Methods

      A database was used to examine demographics of patients undergoing TJA from May-December 2019 (Pre-COVID-19) and May-December 2020 (Post-COVID-19 restrictions). Categorical covariates were summarized by reporting counts and percentages and compared using Fisher exact tests. Continuous covariates were summarized by reporting means and standard deviations. Two-sample t-tests were used for continuous covariates. Equality of TJA counts by year were tested using a test of proportions.

      Results

      There were more TJA procedures performed during the post-COVID-19 period in 2020 vs pre-COVID19 (1151 vs. 882, p<.001). There was an increase in the relative percentage of THAs vs. TKAs performed in 2020 vs 2019 (26.9% vs 18.8%, p<.001), and an increase in patients with Medicaid with a decrease in private insurance (p=.043). The average length of stay was shorter in 2020 with a greater percentage of TJAs performed outpatient ( p<.001). There were no differences in patient sex, race, BMI, smoking status, or age between the two periods.

      Conclusions

      A relative increase in THA procedures, an increase in patients with Medicaid and decrease in private insurance, and a decreased length of stay were seen post COVID-19 restrictions. These trends may reflect pandemic-related changes in insurance status as well as the growing shift to same-day discharge.

      Keywords

      Introduction

      Total joint arthroplasties (TJA, referring collectively to total hip arthroplasty (THA) and total knee arthroplasty (TKA)) are commonly-performed procedures that greatly improve patient quality of life. There are 1 million TJAs performed each year in the United States (US), and this number is expected to quadruple by the year 2030, with a 171% and 189% increase in THA and TKA respectively [
      • Etkin C.D.
      • Springer B.D.
      The American Joint Replacement Registry—the first 5 years.
      ,
      • Sloan M.
      • Premkumar A.
      • Sheth N.P.
      Projected Volume of Primary Total Joint Arthroplasty in the U.S., 2014 to 2030.
      ]. Previous studies have documented disparities in access to care and outcomes [
      • Skinner J.
      • Weinstein J.N.
      • Sporer S.M.
      • Wennberg J.E.
      Racial, Ethnic, and Geographic Disparities in Rates of Knee Arthroplasty among Medicare Patients.
      ,
      • Singh J.A.
      • Lu X.
      • Rosenthal G.E.
      • Ibrahim S.
      • Cram P.
      Racial disparities in knee and hip total joint arthroplasty: An 18-year analysis of national medicare data.
      ]. There are many factors that account for these disparities including: sex, gender, race, ethnicity, insurance status, body mass index (BMI), and Charlson Comorbidity Index (CCI) scores [
      • Singh J.A.
      • Lu X.
      • Rosenthal G.E.
      • Ibrahim S.
      • Cram P.
      Racial disparities in knee and hip total joint arthroplasty: An 18-year analysis of national medicare data.
      ,
      • Zusmanovich M.
      • Kester B.S.
      • Schwarzkopf R.
      Postoperative complications of total joint arthroplasty in obese patients stratified by BMI.
      ]. It is crucial to consider these inequities in TJA and how they might affect patients in all situations.
      In 2020, the COVID-19 pandemic caused an abrupt cessation of elective TJA procedures. Louisiana implemented a ban on all elective surgical procedures beginning March 21, 2020 and ending April 27, 2020 [

      L. (2020, March 21). Healthcare Facility Notice/Order Notice #2020-COVID19-ALL-007. Retrieved December 1, 2020, from https://ldh.la.gov/assets/medicaid/hss/docs/Coronavirus_2019/LDH_Updated_Medical_Surgical_Procedures_03212020.pdf

      ,

      Houston, M. (2020, April 27). Non-emergency surgeries resume at La. hospitals as precautions mitigate COVID-19 threat. Retrieved December 18, 2020, from https://www.wafb.com/2020/04/27/non-emergency-surgeries-resume-la-hospitals-precautions-mitigate-covid-threat/

      ]. Elective TJA cases during the state-ordered restrictions were postponed or canceled entirely.
      The purpose of this study was to analyze the consequences of the COVID-19 elective surgery restrictions on TJA patients by comparing the demographic characteristics of TJA patients in May-December 2020 (the period after restrictions were lifted) to those of patients in May-December of 2019 (the previous year with no restrictions).
      Our hypothesis was that compared with the previous year, patients who underwent TJA procedures most immediately after the cessation of COVID-19 restrictions would be more likely to be white, privately insured, have a lower BMI, and have a lower Charlson Comorbidity Index (CCI) when compared with TJA patients from 2019.

      Materials and Methods

      A private healthcare system database was used to examine the demographics of patients undergoing TJA (CPT codes 27130/primary THA and 27447/primary TKA) in a single state from May to December 2019 (Pre-COVID-19) and May to December 2020 (Post-COVID-19 elective procedure restrictions). Patients with a diagnosis of infection or femoral neck fracture up until the day of the procedure were excluded from the analysis.
      Categorical covariates were summarized by reporting counts and percentages. Continuous covariates were summarized by reporting means and standard deviations. Categorical covariates were compared between COVID-19 groups using Fisher exact tests, while two-sample t-tests were used for continuous covariates. We tested equality of TJA counts by year using a one-sample test of proportions (compared to 50%). Multivariable logistic regression was used to simultaneously adjust for multiple potential confounding variables to see if any individual demographics were associated with an increased likelihood of being treated most quickly after COVID-19 restrictions were lifted. Statistical analyses were conducted using R statistical software version 4.0.2.

      Results

      Table 1 displays the demographic characteristics of patients in both groups. Interestingly, there were more TJA procedures performed during the post-COVID-19 period in 2020 compared with the pre-COVID19 group (1151 vs. 882, p<.001). There was a statistically significant increase in the relative percentage of THAs vs. TKAs performed in 2020 compared to 2019 (26.9% vs 18.8%, p<.001). There were no statistically significant differences in patient sex, race, BMI, smoking status, or age between the two periods overall. An increase in patients with Medicaid insurance with a concurrent decrease in private insurance (p-value=.043) was also seen in 2020 (Table 1). The average length of stay (LOS) was also shorter in 2020 with a greater percentage of TJAs being performed outpatient (p<.001; Table 1).
      Table 1Demographic characteristics based on when the surgery was conducted (Pre/Post Covid-19). Count (%) are reported for categorical variables and mean (sd) were reported for continuous variables. When missing values are present, the number of missing values were listed in parentheses.
      VariableAll (2033)Pre-COVID (882)COVID (1151)P-values% Treated in COVID
      Black Race665 (33.1, 23)281 (32.3, 13)384 (33.7, 10)0.32957.7
      White Race1296 (64.5, 23)564 (64.9, 13)732 (64.2, 10)56.5
      Other Race72 (3.5, 23)37 (4.2, 10)35 (3, 10)48.6
      Male Sex772 (38)327 (37.1)445 (38.7)0.48957.6
      Female Sex1261 (62)555 (62.9)706 (61.3)56
      Private Insurance667 (32.9, 3)309 (35)358 (31.2, 3).04353.7
      Medicaid174 (8.6, 3)60 (6.8)114 (9.9, 3)65.5
      Medicare1110 (54.7, 3)488 (55.3)622 (54.2, 3)56
      Smoker436 (21.4)173 (19.6)263 (22.8)0.08160.3
      Non-Smoker1597 (78.6)709 (80.4)888 (77.2)55.6
      THA476 (23.4)166 (18.8)310 (26.9)<.00165.1
      TKA1557 (76.6)716 (81.2)841 (73.1)54
      Age64.85 (9.48)65.23 (9.41)64.56 (9.52)0.113
      CCI1.05 (1.58)1.03 (1.55)1.07 (1.61)0.557
      LOS0.24 (0.59)0.33 (0.63)0.18 (0.55)<.001
      BMI36.33 (8.71, 9)36.23 (8.9, 9)36.41 (8.57)0.641
      Month8.32 (2.24)8.4 (2.3)8.26 (2.19)0.189
      THA = total hip arthroplasty. TKA = total knee arthroplasty. CCI = Charlson comorbidity index. LOS = length of stay. Month = Month of surgery. BMI = Body Mass Index. Continuous variables are age, CCI, LOS, BMI, and Month.
      Figure 1 is a multivariable logistic regression to predict whether a surgery was done during COVID-19. It suggests that patients with private insurance were significantly less likely to have a TJA during the post-COVID-19 restrictions period than publicly insured patients (adjusted OR = .71, CI=.58-.87, p=.001). It also shows that THAs were more likely to be performed than TKAs during the post-COVID-19 restrictions period (adjusted OR = 1.61, CI = 1.29-2.01), and that increased age was associated with a decreased likelihood of undergoing TJA during the post-COVID-19 period (aOR = .99, CI = .98-1, p=.048).
      Figure thumbnail gr1
      Figure 1Multivariable logistic regression to predict whether a surgery was done during COVID-19.
      Figures 2 and 3 display longitudinal information on various patient demographics from May to December in the pre- and post- COVID-19 time periods. Though not statistically significant between the two periods in their entirety, there was an increase in the number of Black patients in October of 2020 (Figure 2). This increase does not seem to correlate with other measured patient demographics in October 2020. In October 2019, there was a large increase in the amount of patients who smoke compared to October 2020 (Figure 2). There was a similar increase in the CCI scores in October 2019 patients, which may indicate that smoking and medical comorbidities are linked in this patient population (Figures 3).
      Figure thumbnail gr2
      Figure 2Demographic % by month in 2019 (dotted) and 2020 (solid).
      Figure thumbnail gr3
      Figure 3Mean of continuous demographic information by month in 2019 (dotted) and 2020 (solid).

      Discussion

      In total, there were more TJA procedures performed in this private healthcare system from May-December 2020 than in May-December 2019. In contrast, there was a decline in all elective procedures on the national scale [
      • Mattingly A.S.
      • Rose L.
      • Eddington H.S.
      • Trickey A.W.
      • Cullen M.R.
      • Morris A.M.
      • Wren S.M.
      Trends in US surgical procedures and health care system response to policies curtailing elective surgical operations during the COVID-19 pandemic.
      ]. Of those 2020 TJAs, a greater percentage were THA compared to 2019. The increase in TJAs from May-December 2020 may have been a result of a backlog caused by elective procedure restrictions, causing more operations to be performed in this timeframe. In a separate study analyzing changes in THA procedures post-COVID, the backlog theory seems to be supported. In that study, quarter 2 of 2020 had a 68.8% decline in THA, while quarter 3 rebounded to the pre-pandemic baseline, then quarter 4 settled at 81.5% of baseline [
      • Gordon A.M.
      • Magruder M.L.
      • Ng M.K.
      • Sheth B.K.
      • Conway C.A.
      • Hang Jason Wong C.
      The combined effect of policy changes and the COVID-19 pandemic on the same day discharge and complications following total hip arthroplasty: A nationwide analysis.
      ]. These results suggest that a bottleneck occurred in the period after COVID elective procedure bans. Our study is unique in that our presumed “bottleneck” resulted in a significant increase in total TJA procedures in the post-COVID period rather than the significant reduction experienced on the national level [
      • Mattingly A.S.
      • Rose L.
      • Eddington H.S.
      • Trickey A.W.
      • Cullen M.R.
      • Morris A.M.
      • Wren S.M.
      Trends in US surgical procedures and health care system response to policies curtailing elective surgical operations during the COVID-19 pandemic.
      ].
      Contrary to our hypothesis, our analysis revealed that the proportion of patients who underwent a TJA with Medicaid insurance increased from May-December 2020 when compared to 2019. This could be in part caused by a general increase in the number of Medicaid enrollees as a result of COVID-related unemployment. According to enrollment data published by the Centers for Medicare and Medicaid Services, as of May 2022, Medicaid enrollment increased by 17,939,614 individuals (28%) between February 2020 and May 2022 [].
      Contrary to our hypothesis, we found no significant difference in the patient sex, race, BMI, smoking status, or age between the two groups. This is in concurrence with Gordon and colleagues, who analyzed the demographics of THA patients in the post-COVID period on the national scale [
      • Gordon A.M.
      • Magruder M.L.
      • Ng M.K.
      • Sheth B.K.
      • Conway C.A.
      • Hang Jason Wong C.
      The combined effect of policy changes and the COVID-19 pandemic on the same day discharge and complications following total hip arthroplasty: A nationwide analysis.
      ]. Of note, there are few studies analyzing these particular demographic characteristics in TJA patients in the post-COVID period. To our knowledge, our study is the only study to do so on a regional scale.
      Our analysis of LOS revealed that 2020 TJA patients stayed in the hospital a significantly shorter amount of time when compared to their 2019 counterparts. A decrease in LOS was also observed nationally in the post-COVID period [
      • Gordon A.M.
      • Magruder M.L.
      • Ng M.K.
      • Sheth B.K.
      • Conway C.A.
      • Hang Jason Wong C.
      The combined effect of policy changes and the COVID-19 pandemic on the same day discharge and complications following total hip arthroplasty: A nationwide analysis.
      ]. This reflects a significant shift to outpatient TJA operations as opposed to the more standard inpatient protocol [
      • Lovett-Carter D.
      • Sayeed Z.
      • Abaab L.
      • Pallekonda V.
      • Mihalko W.
      • Saleh K.J.
      Impact of outpatient total joint replacement on postoperative outcomes.
      ]. This finding is in contrast to a study published by Green and colleagues. They found that LOS was significantly higher upon post-COVID-19 recommencement of elective orthopedic procedures. This was attributed to potential clinical and radiological deterioration of arthritis and musculoskeletal conditioning during longer wait times until surgery, which may have affected postoperative outcomes [
      • Green G.
      • Abbott S.
      • Vyrides Y.
      • Afzal I.
      • Kader D.
      • Radha S.
      The impact of the COVID-19 pandemic on the length of stay following total hip and knee arthroplasty in a high volume elective orthopaedic unit.
      ]. Our finding, however, is similar to a study by Cherry and colleagues. They found that same day discharges were increased in those who underwent non-direct anterior approach THAs and TKAs in 2020 vs 2019. This was reported to be due to the desire to minimize risk of exposure to COVID-19 and to minimize inpatient bed use [
      • Cherry A.
      • Montgomery S.
      • Brillantes J.
      • Osborne T.
      • Khoshbin A.
      • Daniels T.
      • Ward S.E.
      • Atrey A.
      Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19.
      ].
      We similarly suspect that our observed decrease in LOS is due to the stresses put on the healthcare system by the COVID-19 pandemic. These stressors include: 1) a decrease in staff (due to illness and/or burnout); 2) a decrease in facilities due to the need to convert large sections of hospitals into COVID-specific intensive care units; 3) the potential risk of contracting COVID-19 as a recovering patient in the hospital. We must also consider that beginning in 2020, THA was removed from the Centers for Medicare and Medicaid Services (CMS) list of “inpatient-only” procedures [
      • Lynch J.C.
      • Yayac M.
      • Krueger C.A.
      • Courtney P.M.
      Amount of CMS reduction in facility reimbursement following removal of total hip arthroplasty from the inpatient-only list far exceeds reduction in actual care cost.
      ]. This action by the CMS, in combination with the aforementioned COVID-era challenges posed to hospitals, likely contributed to the observed decrease in LOS.

      Conclusions

      In the time-period after elective surgery restrictions were put in place due to COVID-19 precautions, there was a relative increase in THA procedures as a proportion of total TJA and an increase in patients with Medicaid insurance. We also saw a decreased LOS following TJA. These trends may reflect reaction to a backlog of previously postponed procedures, pandemic-related changes in insurance status due to job loss, as well as the growing shift to same-day discharge TJA. Further research should be done in the coming years to investigate whether these trends continue, as well as how the COVID-19 pandemic may have affected postoperative outcomes.

      Conflict of Interests

      ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Acknowledgements

      The authors would like to acknowledge Vinod Dasa, Dan Fort, Deryk Jones, Peter Krause, and Lauren Leslie for their help acquiring the data.

      Appendix A. Supplementary data

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