The JBJS fast-track articles about COVID-19 have so far addressed clinical and education/training challenges, but the latest one, by Anoushiravani et al., examines macro- and microeconomic issues.
The cessation of elective surgery has stressed the financial viability of many healthcare organizations, large and small. The US healthcare system relies disproportionately on elective surgical procedures as a revenue source, with those revenues often used to indirectly subsidize the care of other patients. Private orthopaedic practices spend >$33,000 per month per surgeon to maintain overhead for their offices and are consequently also reliant on elective procedures. Nationally, a substantial contraction within the healthcare sector will greatly contribute to growing unemployment and recession in the overall economy.
The $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act designates $100 billion to hospitals and hospital systems to help defray expenses relating to constructing temporary structures and obtaining medical supplies during the pandemic. The CARES Act also designates $350 billion in new loans to small businesses, which include private orthopaedic practices. The program most applicable to those practices is the Paycheck Protection Program (PPP), which provides a maximum of $10 million or 2.5 times the business’s average monthly payroll in 2019. Unfortunately, given the high capital expenditure inherent in orthopaedic practices, the PPP may not be sufficient for the largest groups.
During times of hardship, healthcare professionals, regardless of their training, tend to come together and do what is best for their patients, families, and colleagues. For example, the Rothman Institute in Philadelphia is currently retaining employees by temporarily not paying its surgeons.
Anoushiravani et al. recommend a continued reduction in all nonessential procedures as we move through the most critical pandemic period. In addition, they urge all private orthopaedic practices to study the PPP guidelines to determine how this program can best apply to their group.
To help prevent a second outbreak after the peak in COVID-19 cases recedes, the authors call for the following 2 measures:
- Availability of accurate, timely testing for all who are involved in surgical care, especially reliable antibody tests demonstrating immunity
- National guidelines for returning to normal elective surgical schedules
The last JBJS fast-track article cited the need for clearer definitions of “elective” orthopaedic surgery amid the COVID-19 pandemic. As if in response to that, the newest JBJS fast-track article by DePhillipo et al. further explores the moving-target distinction between elective and necessary orthopaedic surgery. The authors also delineate the possible role of ambulatory surgical centers (ASCs) in handling outpatient surgical procedures that were previously scheduled for inpatient facilities.
Absent clear recommendations about which procedures should be considered important enough to be performed in ASCs, DePhillipo et al. offer the following general suggestions:
- Acute and/or disabling injuries to health-care workers, first responders, and members of the military and police and fire departments
- Osseous fractures and/or irreducible joint dislocations
- Wound/joint infections or postoperative wound dehiscence
- Pathologies that could lead to long-term disability and chronic pain if acute surgical management is delayed
The most specific and valuable information in this article is a table that lists, joint-by-joint, acute orthopaedic injuries that the authors deem “surgically necessary” or “elective-urgent procedures,” along with justifications for each. The authors note that the list is far from “a medical directive or standard of care,” but they propose an interesting rationale for fewer restrictions on elective procedures for low-risk individuals: those who are currently restricted from work or unemployed would have the opportunity to have and recover from surgery and be ready to reenter the work force when the time comes.
Finally, the authors offer best-practice guidance for ASCs in the current climate:
- Limit visitors to all but minor patients, the mentally/physically disabled, and elderly patients who require assistance.
- Administer appropriate screening of patients and staff for signs of illness or other risk factors.
- Ensure that all who are present during intubation and extubation have access to appropriate personal protective equipment, including N95 masks.
As Sarac et al. note in the latest JBJS fast-tracked article, the phrase “elective procedure” is ambiguous, even though it is supposed to identify procedures that are being postponed to help hospitals cope with the COVID-19 pandemic. Guidelines from the Centers for Disease Control and Prevention (CDC) say that operations for “most cancers” and “highly symptomatic patients” should continue, but that leaves much of the ambiguity unresolved. What constitutes an elective procedure in orthopaedics at this unusual time remains unclear.
To help clarify the situation, the authors summarize guidance issued by states and describe the guidelines currently in use for orthopaedic surgery at their institution, The Ohio State University College of Medicine.
Here are the state-related data collected by Sarac et al., as of March 24, 2020:
- 30 states have published guidance regarding discontinuation of elective procedures; 16 of those states provide a definition of “elective” or offer guidance for determining which procedures should continue to be performed.
- 5 states provide guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly permit trauma-related procedures, and 4 states recommend against performing arthroplasty.
- 10 states provide guidelines permitting the continuation of oncological procedures.
In the Buckeye State, the Ohio Hospital Association asked each hospital and surgery center to cancel procedures that do not meet any of the following criteria:
- Threat to a patient’s life if procedure is not performed
- Threat of permanent dysfunction of an extremity or organ system
- Risk of cancer metastasis or progression of staging
- Risk of rapid worsening to severe symptoms
Mindful of those criteria, individual surgical and procedural division directors at the authors’ university developed a list of specific procedures that should continue to be performed. Respective department chairs approved the lists, which were then sent to the hospital chief clinical officer for signoff.
The authors tabulate the orthopaedic procedures that continue to be performed at their institution as of March 25, 2020, but they are quick to add that even this list is not without ambiguity. For example, surgery should continue on “select closed fractures that if left untreated for >30 days may lead to loss of function or permanent disability,” but that requires surgeons to judge, in these uncertain and fluid times, which fractures necessitate fixation in the short term.
Sarac et al. emphasize that such lists, however specific they are today, are likely to change as demands on hospitals shift. They suggest that as the pandemic evolves, a further classification of procedures into 2 time-based categories might be helpful: (1) those that need to be performed within 2 weeks and (2) those that need to be performed within 4 weeks. Sarac et al. also remind orthopaedic surgeons to provide patients waiting for surgery that has been postponed with information regarding safe and effective methods of managing their pain.