Perception of Patients on the Waiting List for Total Hip Arthroplasty on the Resumption of Elective Surgeries during the COVID-19 Pandemic

Keywords

COVID-19 - elective surgical procedures - arthroplasty, replacement, hip - patient perception of surgery

Introduction

Since March 2020, the new coronavirus (COVID-19) pandemic began to interfere with the functioning of the publicly funded health care system – Sistema Único de Saúde (SUS) – in Brazil. With the increase in the occupation of beds in intensive care units, state and municipal governments and public and private health managers have chosen to suspend elective surgeries. This was one of the measures taken to contain transmission, reduce hospitalizations and make beds available for critically ill patients with COVID-19. The economic and social impact of restrictions on elective orthopedic hip surgeries and the perception of patients regarding the resumption of surgeries remain poorly studied in our country.

There is no study in Brazil that estimates the damage resulting from the stoppage of elective surgeries in the country. However, data from the American Hospital Association estimate that, in that country, losses to hospitals and health services could reach the mark of 202 billion dollars.[1] More than half of Americans reported a decrease in income since the pandemic began, and the unemployment rate has risen sharply.[2]

The social impact of suspending surgeries is directly related to the reduction in patients' quality of life. 100 patients awaiting orthopedic surgery, of whom 70 were scheduled for primary arthroplasty or revision arthroplasty of the hip or knee were interviewed at University College London Hospital. Their results indicated that approximately 90% would like to undergo the procedure as soon as possible.[3] This reflects the deterioration in the quality of life of patients living with osteoarthritis of the knee and hip.[4] Among patients on the waiting list for total hip arthroplasty (THA), it was observed that 33% consider their quality of life worse than death, in addition to there being an association between time on the waiting list and loss of quality of life.[5]

The patients' perception of the possibility of resuming activities is an important factor that requires further studies. In the United States, there are data demonstrating that men would be more interested in performing elective surgeries more quickly than women, after the removal of restrictions due to COVID-19. And most respondents are concerned about contracting the virus while hospitalized for surgery, as well as exposing their family members to the virus.[6]

Due to the scarcity of data that may reflect the local reality on the effects of postponing elective surgeries and patients' expectations, this study sought to study the profile of patients on the waiting list for total hip arthroplasty and their perception of the pandemic and the impact it has on their lives.

Material and methods

This study was approved by the Research Ethics Committee of our Institution and inserted in the Brazil Platform (CAAE-47957921.7.0000.0020) and the informed consent form was provided and signed by the research participants.

From July to November 2021, thirty-nine patients on the waiting list for total hip arthroplasty (THA) at a university hospital were assessed using a questionnaire prior to surgery. The questionnaire was applied during an outpatient consultation by a specialist in hip surgery (Appendix 1). Patients over 18 years of age with an indication for THA were included. Patients awaiting THA surgery due to fracture of the proximal femur were excluded from the study.

The collected data were summarized with the preparation of frequency tables and contingency tables. To compare the groups with regard to categorical variables, the Chi-square test or Fisher's exact test was applied, for quantitative variables the Mann-Whitney test was applied. The results were calculated using the Statistica program version 7.

Results

A total of 39 patients answered the questionnaire. The patients were, on average, 58.95 years old (ranging from 26 to 93 years old), with just over half being male (53.85%). More than 75% of patients had an income of less than three minimum wages per family member. [Table 1] represents the demographic profile of the studied sample.

Table 1

Characteristics	N	%
Sex
Male	21	53.85
Female	18	46.15
Age range (years)
18-39	2	6.02
40-49	6	15.38
50-59	15	38.46
60-69	5	12.82
>70	11	28.21
Civil status
Married	28	71.79
Single	3	7.69
Widower	5	12.82
Divorced	3	7.69
Race
White	34	87.18
Black	3	7.69
Brown/Mestizos	2	5.13
Minimum wages per person in the family
Up to 1	16	41.03
1-3	14	35.90
3-6	4	10.26
6-10	4	10.26
>10	1	2.56
Number of people living in the same household
1	4	10.26%
2	15	38.46%
3	13	33.33%
4 or more	7	17.95%
Lives with or cares for people over 60
No	31	81.58%
Yes	7	18.42%
Works or lives with someone who works in essential services
No	26	66.67%
Yes	13	33.33%
Job loss in the pandemic (patient or family member)
No	30	76.92%
Yes	9	23.08%
Receive sick pay
No	29	74.36%
Yes	10	25.64%
Complete immunization for COVID
No	21	53.85%
Yes	18	46.15%
Comorbidities
Obesity	12	30.77%
Diabetes Mellitus	11	28.21%
Systemic Arterial Hypertension	26	66.67%
Smoking	5	12.82%
Alcoholism	1	2.56%

Approximately 60% of patients expressed concern about contracting COVID-19 or exposing their family to the coronavirus after hospitalization for THA. There was no difference between groups by age or sex regarding concern about COVID-19 infection during hospitalization for surgery. The presence of comorbidities also did not influence the responses (p = 0.29). There was a statistical difference between the proportion of vaccinated individuals between age groups, being greater in patients over 60 years of age (p = 0.004). However, complete vaccination did not confer less concern about COVID-19 infection (p = 0.24).

Patients were asked about their perception of the severity of the symptoms they could manifest in case of COVID-19 infection (no symptoms, with mild symptoms, with moderate symptoms without risk of death and moderate with risk of death). More than 70% of respondents believe that if they become infected with COVID-19, they will only experience mild symptoms. Considering patients over 60 years old, the belief that they would only have mild symptoms was 68.75%. There was no significant difference in responses when comparing age groups (p = 0.45).

Nearly 75% stated that their pain score is 8 or more and that they had been waiting for total hip replacement surgery for more than 12 months. Approximately 60% of respondents feel harmed by the delay in surgery.

More than 80% of the participants stated that they would feel comfortable with undergoing the surgery within one month, after approval of elective surgeries by the competent bodies.

They were asked which place or situation in the hospital they were most concerned about the risk of being contaminated by COVID-19. More than 60% of the participants stated that admission and the waiting room are the most worrisome environments, with the hospitalization room and post-operative recovery area in second place, contact with the assistant teams in third and, lastly, the operating room.

When asked whether the risk of contamination is higher or lower during hospitalization compared to daily activities, about 40% responded that there is a higher risk in the hospital. The risk was considered lower in the hospital environment for 39% and equal for 21%. There was no significant difference between age groups regarding this proportion (p = 0.55).

More than 23% of respondents lost their jobs during the pandemic or had a family member who became unemployed. There was a significant difference between age groups (p = 0.04), with younger people (less than 60 years old) presenting significantly more cases of job loss. On the other hand, the younger group benefited from income supplementation through government programs such as sick pay (p = 0.002).

More than 85% of respondents would like the first outpatient consultation after surgery to be face-to-face, while the rest would opt for telemedicine. There was no significant difference between the age groups regarding this proportion (p = 0.28).

Discussion

The average age of the studied population, 58.95 years, was within the expected range, considering the prevalence of coxarthrosis in the adult population. The hypotheses that the presence of more comorbidities, incomplete vaccination for COVID-19, higher age group and female gender would be associated with greater fear of contracting COVID-19 when hospitalized for total hip arthroplasty was not confirmed after statistical analysis.

Females were more concerned about the risk of COVID-19 infection (64.71% versus 52.38% of males) and 58.82% of females were afraid of exposing their family members to the COVID-19 virus after the hospitalization. Although we did not find statistical significance for this difference between genders in our population, the findings confirm the results of another study in which this concern is more prevalent in women.[6] The average of patients who are concerned about contracting COVID-19 during hospitalization (57.9%) is similar to data from surveys carried out in other countries, where the rate was 61% and 53%.[3] [6] [7]

It was expected that patients over 60 years of age would be more concerned about contracting COVID-19 or fear of developing more severe symptoms due to general knowledge about the epidemiology of the disease. However, there was no significant difference in responses when comparing the age groups (p = 0.45). 68.75% of the elderly believe that if they were infected, they would evolve with the mild form of the disease, which did not differ significantly from respondents aged less than 60 years (72.73%).

There was no statistically significant difference when patients answered whether they considered the hospital a place with a higher risk of exposure and contamination to COVID-19 when compared to daily activities. This finding may reflect the diversity of the population's exposure level, considering that patients who are more restricted to the home environment, who do not use public transport or do not work outside the home, would be less exposed. On the other hand, patients with a routine of more contact with other people at work, with neighbors, family members would be more likely to become infected and considered the hospital to be safer. Assessing this perception of patients was important because in periods when the government is free to perform the procedure, most patients who canceled their surgery mentioned concerns about contracting COVID-19 as the main reason. Therefore, patients who consider the hospital as a place with a higher risk of transmitting COVID-19 are subject to canceling their surgeries.[7]

Most patients (58.9%) felt that the delay in having their total hip arthroplasty surgery had been delayed. This finding reinforces the loss of quality of life that patients with hip arthrosis suffer.[4]

Ho et al.[7] found an association between patients' agreement to undergo elective orthopedic surgery and the perception that their situation was serious or getting worse. In our study, we did not find an association between greater pain intensity and the prevalence of agreeing to undergo surgery in less than 30 days after the application of the questionnaire. Considering that trust in hospitals and in the health system is a necessary factor to undergo elective surgery,[7] it is possible that the caution in waiting more than 30 days for the procedure was due to the understanding that the collapse of public health, in the country, did not provide the ideal time for hospitalization. During the study, the country suffered from a lack of infirmary and intensive care beds in public and private hospitals.

After the first wave of COVID-19 in England, the desire of patients to have their total hip replacement performed during the pandemic was evaluated. 94.7% of patients wanted to undergo surgery as soon as possible.[3] On the other hand, our study showed that 81.58% of patients wanted to undergo surgery in less than 30 days. The difference found can be explained by several factors. The questionnaires applied in our study were initially applied when there was still a ban on elective surgeries due to the large number of new cases, deaths and hospitalizations due to COVID-19 in the country. It is also possible that the difference is due to the fact that we do not have the same perioperative care protocol that could reduce intra-hospital contamination, such as the requirement of negative PCR tests for COVID-19 and preoperative isolation lasting 14 days; in addition to not informing that the hospital was being considered a "COVID-free zone", in which suspected or confirmed cases of COVID-19 were not seen or treated.

At our institution, patients undergoing hip arthroplasty are hospitalized and most are discharged on the second postoperative day. In other services there is the possibility of hospital discharge within 24 hours. It is possible to suggest that the estimate of staying longer in the hospital, where there may be patients hospitalized for COVID-19, in the postoperative period may negatively influence the desire to operate as soon as possible due to the fear of being contaminated or becoming ill during hospitalization.

In the second and third quarters of 2021, unemployment in Brazil reached rates of 14.9 and 14.2%, according to data from the Brazilian Institute of Geography and Statistics (IBGE).[8] The economic impact was mainly reflected in the 23.08% of patients who lost their jobs or family members during the pandemic, especially for the group under 60 years old (p = 0.04).

Despite the fear of contracting COVID-19, 85% of patients would like the first postoperative consultation to be face-to-face instead of telemedicine. The data may be related to the difficulty of accessing the internet and lack of the ability to make effective use of electronic devices. Even if there were no such difficulties, it is possible that the desire to have the physical examination, assessment of the surgical wound and removal of stitches performed in the first postoperative consultation led most to prefer a face-to-face consultation.

Conclusion

The study evaluated the perception of patients on the waiting list for total hip arthroplasty during the COVID-19 pandemic. Most patients felt hampered by cancellations and delays of elective surgeries and concerns about becoming infected or exposing family members to COVID-19 after surgery. The economic impact of the pandemic was revealed by the rate of 23% of respondents who lost or had a family member who lost their jobs during the pandemic, being higher in patients younger than 60 years (p = 0.04).

• Referências

• 1 Kaye AD, Okeagu CN, Pham AD. et al. Economic impact of COVID-19 pandemic on healthcare facilities and systems: International perspectives. Best Pract Res Clin Anaesthesiol 2021; 35 (03) 293-306
• 2 Swagel P. CBO's current projections of output, employment, and interest rates and a preliminary look at federal deficits for 2020 and 2021. Washington, DC: Congressional Budget Office; 2020
• 3 Wignadasan W, Mohamed A, Kayani B, Magan A, Plastow R, Haddad FS. Restarting elective orthopaedic surgery as COVID-19 lockdown restrictions are reduced : have patient perceptions towards surgery changed?. Bone Jt Open 2021; 2 (10) 865-870
• 4 Brown TS, Bedard NA, Rojas EO. et al; AAHKS Research Committee. The Effect of the COVID-19 Pandemic on Electively Scheduled Hip and Knee Arthroplasty Patients in the United States. J Arthroplasty 2020; 35 (7S): S49-S55
• 5 Scott CEH, MacDonald DJ, Howie CR. ‘Worse than death’ and waiting for a joint arthroplasty. Bone Joint J 2019; 101-B [phone]
• 6 Moverman MA, Puzzitiello RN, Pagani NR, Barnes CL, Jawa A, Menendez ME. Public perceptions of resuming elective surgery during the COVID-19 pandemic. J Arthroplasty 2021; 36 (02) 397-402.e2
• 7 Ho SWL, Tan TL, Lee KT. Elective orthopaedic surgery and COVID-19: knowledge and perceptions of patients in a global pandemic. Singapore Med J 2021; 62 (10) 554-558
• 8 IBGE – Instituto Brasileiro de Geografia e Estatística. Painel de Indicadores [Acesso em 19 de fevereiro de 2022]. Disponível em: https://www.ibge.gov.br/indicadores#desemprego