Did the Physical and Mental Health of Orthopaedic Patients Change After the Onset of the COVID-19 Pandemic?

Abstract

Background

The 2019 novel coronavirus (COVID-19) pandemic has been associated with poor mental health outcomes and widened health disparities in the United States. Given the inter-relationship between psychosocial factors and functional outcomes in orthopaedic surgery, it is important that we understand whether patients presenting for musculoskeletal care during the pandemic were associated with worse physical and mental health than before the pandemic’s onset.

Questions/purposes

(1) Did patients seen for an initial visit by an orthopaedic provider during the COVID-19 pandemic demonstrate worse physical function, pain interference, depression, and/or anxiety than patients seen before the pandemic, as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) instrument? (2) During the COVID-19 pandemic, did patients living in areas with high levels of social deprivation demonstrate worse patterns of physical function, pain interference, depression, or anxiety on initial presentation to an orthopaedic provider than patients living in areas with low levels of social deprivation, compared with prepandemic PROMIS scores?

Methods

This was a retrospective, comparative study of new patient evaluations that occurred in the orthopaedic department at a large, urban tertiary care academic medical center. During the study period, PROMIS computer adaptive tests were routinely administered to patients at clinical visits. Between January 1, 2019, and December 31, 2019, we identified 26,989 new patients; we excluded 4% (1038 of 26,989) for being duplicates, 4% (1034 of 26,989) for having incomplete demographic data, 44% (11,925 of 26,989) for not having a nine-digit home ZIP Code recorded, and 5% (1332 of 26,989) for not completing all four PROMIS computer adaptive tests of interest. This left us with 11,660 patients in the “before COVID-19” cohort. Between January 1, 2021 and December 31, 2021, we identified 30,414 new patients; we excluded 5% (1554 of 30,414) for being duplicates, 4% (1142 of 30,414) for having incomplete demographic data, 41% (12,347 of 30,414) for not having a nine-digit home ZIP Code recorded, and 7% (2219 of 30,414) for not completing all four PROMIS computer adaptive tests of interest. This left us with 13,152 patients in the “during COVID-19” cohort. Nine-digit home ZIP Codes were used to determine patients’ Area Deprivation Indexes, a neighborhood-level composite measure of social deprivation. To ensure that patients included in the study represented our overall patient population, we performed univariate analyses on available demographic and PROMIS data between patients included in the study and those excluded from the study, which revealed no differences (results not shown). In the before COVID-19 cohort, the mean age was 57 ± 16 years, 60% (7046 of 11,660) were women, 86% (10,079 of 11,660) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 47 ± 25. In the during COVID-19 cohort, the mean age was 57 ± 16 years, 61% (8051 of 13,152) were women, 86% (11,333 of 13,152) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 46 ± 25. The main outcome measures in this study were the PROMIS Physical Function ([PF], version 2.0), Pain Interference ([PI], version 1.1), Depression (version 1.0), and Anxiety (version 1.0). PROMIS scores follow a normal distribution with a mean t-score of 50 and a standard deviation of 10. Higher PROMIS PF scores indicate better self-reported physical capability, whereas higher PROMIS PI, Depression, and Anxiety scores indicate more difficulty managing pain, depression, and anxiety symptoms, respectively. Clinically meaningful differences in PROMIS scores between the cohorts were based on a minimum clinically important difference (MCID) threshold of 4 points. Multivariable linear regression models were created to determine whether presentation to an orthopaedic provider during the pandemic was associated with worse PROMIS scores than for patients who presented before the pandemic. Regression coefficients (ß) represent the estimated difference in PROMIS scores that would be expected for patients who presented during the pandemic compared with patients who presented before the pandemic, after adjusting for confounding variables. Regression coefficients were evaluated in the context of clinical importance and statistical significance. Regression coefficients equal to or greater than the MCID of 4 points were considered clinically important, whereas p values < 0.05 were considered statistically significant.

Results

We found no clinically important differences in baseline physical and mental health PROMIS scores between new patients who presented to an orthopaedic provider before the COVID-19 pandemic and those who presented during the COVID-19 pandemic (PROMIS PF: ß -0.2 [95% confidence interval -0.43 to 0.03]; p = 0.09; PROMIS PI: ß 0.06 [95% CI -0.13 to 0.25]; p = 0.57; PROMIS Depression: ß 0.09 [95% CI -0.14 to 0.33]; p = 0.44; PROMIS Anxiety: ß 0.58 [95% CI 0.33 to 0.84]; p < 0.001). Although patients from areas with high levels of social deprivation had worse PROMIS scores than patients from areas with low levels of social deprivation, patients from areas with high levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the pandemic were compared (PROMIS PF: ß -0.23 [95% CI -0.80 to 0.33]; p = 0.42; PROMIS PI: ß 0.18 [95% CI -0.31 to 0.67]; p = 0.47; PROMIS Depression: ß 0.42 [95% CI -0.26 to 1.09]; p = 0.23; PROMIS Anxiety: ß 0.84 [95% CI 0.16 to 1.52]; p = 0.02).

Conclusion

Contrary to studies describing worse physical and mental health since the onset of the COVID-19 pandemic, we found no changes in the health status of orthopaedic patients on initial presentation to their provider. Although large-scale action to mitigate the effects of worsening physical or mental health of orthopaedic patients may not be needed at this time, orthopaedic providers should remain aware of the psychosocial needs of their patients and advocate on behalf of those who may benefit from intervention. Our study is limited in part to patients who had the self-agency to access specialty orthopaedic care, and therefore may underestimate the true changes in the physical or mental health status of all patients with musculoskeletal conditions. Future longitudinal studies evaluating the impact of specific COVID-19-related factors (for example, delays in medical care, social isolation, or financial loss) on orthopaedic outcomes may be helpful to prepare for future pandemics or natural disasters.

Level of Evidence

Level II, prognostic study.

Introduction

The economic, social, and healthcare-related disruptions caused by the 2019 novel coronavirus (COVID-19) pandemic has had a profound impact on mental health and well-being in the United States. It has been widely reported that the prevalence of mental health–related disorders, including depression, anxiety, and post-traumatic stress disorder symptoms, has increased since the onset of the pandemic [6, 8, 11, 23, 30]. In the orthopaedic population, we would expect that worsening mental health would lead to poor patient outcomes, because there is strong evidence demonstrating an inter-relationship among physical, mental, and social health. For example, worse preoperative psychosocial factors, including mood and attitudinal factors and social support, predict poor surgical outcomes, including persistent pain, increased disability, and poor satisfaction, for patients with musculoskeletal conditions [7, 14, 28]. However, given that patients seeking specialty orthopaedic care represent a select subset of the general population, changes in health status may differ from those observed nationally. Therefore, to identify gaps in orthopaedic care and address the unique needs of our patient population, it is important that we specifically assess whether orthopaedic patients during the pandemic had worse physical and mental health than patients seen before the beginning of the pandemic.

Separately, studies have indicated that the COVID-19 pandemic has disproportionately affected people from communities with fewer social and economic resources [22]. Specifically, these communities suffered higher rates of COVID-19 disease and poorer mental health outcomes than the general United States population [1, 16, 21]. As it relates to orthopaedic surgery, patients from communities with higher levels of social deprivation already have worse perceived physical and mental health than patients from less-deprived areas [9, 24, 33]. We are therefore concerned about this disparity in physical and mental health between orthopaedic patients from communities with high and low levels of social deprivation, and how this disparity has widened since the onset of the pandemic. As we work toward addressing disparities in orthopaedic surgery, it is important that we understand whether orthopaedic patients from communities with greater levels of social deprivation were experiencing worse physical and mental health during the pandemic than those before the pandemic’s onset.

In this study, we asked: (1) Did patients seen for an initial visit by an orthopaedic provider during the COVID-19 pandemic demonstrate worse physical function, pain interference, depression, or anxiety than patients seen before the pandemic, as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) instrument? (2) During the COVID-19 pandemic, did patients living in areas with high levels of social deprivation demonstrate worse patterns of physical function, pain interference, depression, or anxiety on initial presentation to an orthopaedic provider than patients living in areas with low levels of social deprivation, compared with prepandemic PROMIS scores?

Patients and Methods

Study Design and Setting

This was a retrospective, comparative study of patients who presented for a new visit to an orthopaedic provider at a large, urban, tertiary care academic medical center before (January 1, 2019 to December 31, 2019) and during (January 1, 2021 to December 31, 2021) the COVID-19 pandemic. The academic medical center is located in St. Louis, Missouri and serves patients from urban, suburban, and rural areas across Missouri, southern Illinois, and other surrounding states. This study design is consistent with prior studies evaluating population-level changes in health status between cohorts before and after the onset of the COVID-19 pandemic [8, 18].

Participants

Using our electronic medical record, we identified new adult (age ≥ 18 years) patients who presented to an orthopaedic provider at our academic medical center. In 2019, we identified 26,989 patients; we excluded 4% (1038 of 26,989) for being duplicates, 4% (1034 of 26,989) for having incomplete demographic data, 44% (11,925 of 26,989) for not having a nine-digit home ZIP Code recorded, and 5% (1332 of 26,989) for not completing all four PROMIS computer adaptive tests of interest (Fig. 1). This left us with 11,660 patients in the “before COVID-19” cohort. In 2021, we identified 30,414 patients; we excluded 5% (1554 of 30,414) for being duplicates, 4% (1142 of 30,414) for having incomplete demographic data, 41% (12,347 of 30,414) for not having a nine-digit home ZIP Code recorded, and 7% (2219 of 30,414) for not completing all four PROMIS computer adaptive tests of interest. This left us with 13,152 patients in the “during COVID-19” cohort. To ensure patients who met the inclusion criteria represented our overall practice, we performed an exploratory univariate analysis of available baseline demographic and PROMIS data between patients included in and excluded from this study, which revealed no differences (results not shown).

Fig. 1.

This flowchart shows the patients who were included in and excluded from this study.

Patient Variables

The following patient variables were collected from the electronic medical record: age (in years), gender (women and men), self-reported race and ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic, and other), home address (including nine-digit ZIP Code), payor (commercial, Medicare, Medicaid, workers compensation, or self-pay), smoking status (never, former, or current), and orthopaedic subspeciality (nonoperative, upper extremity, joint reconstruction [knee and hip], foot and ankle, spine, trauma, oncology, and sports medicine). Nonoperative as an orthopaedic subspeciality refers to patients who were seen by a nonoperative provider including physiatrists, physician assistants, and nurse practitioners. The Area Deprivation Index (ADI) was determined for each patient using their nine-digit home ZIP Code. The ADI is a validated, neighborhood-level composite measure of social deprivation that accounts for factors such as income, education, employment, housing quality, and access to material resources [29]. Higher ADI values indicate patients living in areas with higher levels of social deprivation (resource-limited neighborhoods). We used national ADI percentile rankings to define a patient’s level of social deprivation based on national quartile (ADIs from 1 to 25, 26 to 50, 51 to 75, and 76 to 100 were grouped into the first, second, third, and fourth quartiles, respectively). Our ADI analysis focused on patients living in areas qualifying as either the most or least socially deprived national quartiles. This type of analysis has been shown to be one of the best measures for capturing the potential effects of social deprivation on self-reported physical and mental health in orthopaedic patients [5], and has been applied based on national quartiles (high levels of social deprivation [fourth quartile] versus low levels of social deprivation [first quartile]) [9, 33].

Patient Demographics

The cohorts were different regarding age, national ADI quartile, smoking status, and orthopaedic subspeciality (p < 0.05) (Table 1). The cohorts were not different regarding gender, race and ethnicity, and insurance type (p > 0.05). In the before COVID-19 cohort, the mean age was 57 ± 16 years, 60% (7046 of 11,660) were women, 86% (10,079 of 11,660) were White non-Hispanic, and the mean national ADI percentile was 47 ± 25. In the during COVID-19 cohort, the mean age was 57 ± 16 years, 61% (8051 of 13,152) were women, 86% (11,333 of 13,152) were White non-Hispanic, and the mean national ADI percentile was 46 ± 25.

Table 1.

Patient demographics

Characteristic	Before COVID-19 (n = 11,660)	During COVID-19 (n = 13,152)	p value
Age in years, mean ± SD	57 ± 16	57 ± 16	< 0.001
Women, % (n)	60 (7046)	61 (8051)	0.21
Self-reported race or ethnicity, % (n)			0.08
White non-Hispanic	86 (10,079)	86 (11,333)
Black non-Hispanic	10 (1203)	10 (1334)
Hispanic	1 (132)	2 (198)
Other	2 (246)	2 (287)
National ADI quartile, % (n)			< 0.001
First (low social deprivation)	23 (2695)	25 (3280)
Second	35 (4143)	36 (4724)
Third	25 (2961)	24 (3175)
Fourth (high social deprivation)	16 (1861)	15 (1973)
Payor type, % (n)			0.19
Commercial	67 (7799)	68 (8934)
Medicare	30 (3544)	29 (3843)
Medicaid	1.3 (155)	1.5 (202)
Workers compensation	1.0 (119)	0.9 (124)
Self-pay	0.4 (43)	0.4 (49)
Smoking status, % (n)			< 0.001
Never	63 (7314)	65 (8601)
Former	31 (3597)	28 (3639)
Current	6 (749)	7 (912)
Orthopaedic subspecialty, % (n)			< 0.001
Nonoperative	30 (3543)	35 (4536)
Upper extremity	29 (3380)	27 (3588)
Joint reconstruction	19 (2166)	17 (2273)
Foot and ankle	8 (880)	9 (1121)
Spine	7 (859)	6 (743)
Trauma	3 (326)	3 (390)
Oncology	2 (268)	2 (278)
Sports medicine	2 (238)	2 (223)

Data were collected from the electronic medical record. ADI = Area Deprivation Index.

Primary Outcome Measures

The primary outcome measures in this study were the PROMIS Physical Function ([PF], version 2.0), Pain Interference ([PI], version 1.1), Depression (version 1.0), and Anxiety (version 1.0). As part of routine clinical care at our academic medical center, all patients who presented to an orthopaedic provider were asked to complete these PROMIS tests using a self-administered tablet device. PROMIS scores were then generated and uploaded into the patient’s electronic medical record. PROMIS scores are reported as t-scores, which are standardized scores referenced against those of the general United States population. PROMIS scores follow a normal distribution, with a mean t-score of 50 and standard deviation of 10 [4]. Higher PROMIS PF scores indicate better self-reported physical capability, whereas higher PROMIS PI, Depression, and Anxiety scores indicate more difficulty managing pain, depression, and anxiety symptoms, respectively [13]. A minimum clinically important difference (MCID) value of 4 points was used as the threshold for clinically meaningful differences in PROMIS scores between the cohorts, based on previously reported estimates [2, 15, 19].

Ethical Approval

Institutional review board approval with a waiver of informed consent was obtained for this study.

Statistical Analysis

Descriptive statistics were calculated. Continuous variables are presented as mean ± SD, and categorical variables are presented as % (n). We used t-tests and chi-square tests to assess for differences in demographic variables between the cohorts. We used t-tests and Mann-Whitney U tests to assess for differences in mean PROMIS scores for data that followed a normal and non-normal distribution, respectively. Demographic variables that met statistical significance (p < 0.05) on bivariate testing were included in multivariable linear regression models. Multivariable linear regression models were created to determine whether initial presentation to an orthopaedic provider during the pandemic was associated with worse baseline PROMIS scores than for patients who presented before the COVID-19 pandemic. Regression coefficients (ß) represent the estimated difference in PROMIS scores that would be expected for patients who presented during the pandemic compared with patients who presented before the pandemic, after adjusting for confounding variables. Regression coefficients were evaluated in the context of clinical importance and statistical significance. Regression coefficients equal to or greater than the MCID value of 4 points were considered clinically important, whereas p values < 0.05 were considered statistically significant. All statistical analyses were performed in GraphPad Prism version 9.0 (GraphPad).

Results

Differences in PROMIS Scores Between Before and During the Pandemic

We found no clinically important differences in baseline physical and mental health PROMIS scores between new patients who presented to an orthopaedic provider before the COVID-19 pandemic and those who presented during the COVID-19 pandemic (PROMIS PF: ß -0.2 [95% CI -0.43 to 0.03]; p = 0.09; PROMIS PI: ß 0.06 [95% CI -0.13 to 0.25]; p = 0.57; PROMIS Depression: ß 0.09 [95% CI -0.14 to 0.33]; p = 0.44; PROMIS Anxiety: ß 0.58 [95% CI 0.33 to 0.84]; p < 0.001) (Table 2; Supplemental Table 1; http://links.lww.com/CORR/B20). After stratifying patients by orthopaedic subspeciality, we also found no clinically important differences in baseline PROMIS scores between new patients who presented to an orthopaedic provider before the COVID-19 pandemic and those who presented during the COVID-19 pandemic (MCID < 4 points for all analyses; Supplemental Table 2; http://links.lww.com/CORR/B21).

Table 2.

Association between presentation during the COVID-19 pandemic and PROMIS scores after adjusting for age, Area Deprivation Index, smoking status, and orthopaedic subspeciality

Parameter	ß coefficient	95% CI	p value
Physical Function
Cohort (during COVID-19)	-0.2	-0.43 to 0.03	0.09
Pain Interference
Cohort (during COVID-19)	0.06	-0.13 to 0.25	0.57
Depression
Cohort (during COVID-19)	0.09	-0.14 to 0.33	0.44
Anxiety
Cohort (during COVID-19)	0.58	0.33 to 0.84	< 0.001

The ß coefficient reflects the estimated difference in PROMIS score that would be expected for patients who presented during the COVID-19 pandemic compared with patients who presented before the COVID-19 pandemic, after adjusting for confounding variables. For example, patients who presented to an orthopaedic provider during the COVID-19 pandemic would be expected to have a PROMIS Anxiety score of 0.58 points higher than that of patients who presented before the COVID-19 pandemic. Although this result is statistically significant (p < 0.05), 0.58 points is less than the minimum clinically important difference value of 4 points, and therefore the result is interpreted as not clinically important. The other correlations evaluated in this table—physical function, pain interference, and depression—were neither statistically significant nor clinically important. PROMIS = Patient-Reported Outcomes Measurement Information System.

Differences in PROMIS Scores Between Before and During the Pandemic Stratified by ADI

Despite having worse physical and mental health PROMIS scores than patients living in areas with low levels of social deprivation, patients living in areas with high levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the COVID-19 pandemic were compared (PROMIS PF: ß -0.23 [95% CI -0.80 to 0.33]; p = 0.42; PROMIS PI: ß 0.18 [95% CI -0.31 to 0.67]; p = 0.47; PROMIS Depression: ß 0.42 [95% CI -0.26 to 1.09]; p = 0.23; PROMIS Anxiety: ß 0.84 [95% CI 0.16 to 1.52]; p = 0.02) (Table 3; Supplemental Table 3; http://links.lww.com/CORR/B22). Similarly, patients living in areas with low levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the pandemic were compared (PROMIS PF: ß -0.03 [95% CI -0.51 to 0.45]; p = 0.90; PROMIS PI: ß -0.19 [95% CI -0.58 to 0.21]; p = 0.36; PROMIS Depression: ß 0.004 [95% CI -0.48 to 0.48]; p = 0.99; PROMIS Anxiety: ß 0.35 [95% CI -0.15 to 0.85]; p = 0.17).

Table 3.

Association between presentation during the COVID-19 pandemic and PROMIS scores stratified by Area Deprivation Index after adjusting for age, smoking status, and orthopaedic subspecialty

Parameter	ß coefficient	95% CI	p value
High Area Deprivation Index
Physical Function
Cohort (during COVID-19)	-0.23	-0.80 to 0.33	0.42
Pain Interference
Cohort (during COVID-19)	0.18	-0.31 to 0.67	0.47
Depression
Cohort (during COVID-19)	0.42	-0.26 to 1.09	0.23
Anxiety
Cohort (during COVID-19)	0.84	0.16 to 1.52	0.02
Low Area Deprivation Index
Physical Function
Cohort (during COVID-19)	-0.03	-0.51 to 0.45	0.90
Pain Interference
Cohort (during COVID-19)	-0.19	-0.58 to 0.21	0.36
Depression
Cohort (during COVID-19)	0.004	-0.48 to 0.48	0.99
Anxiety
Cohort (during COVID-19)	0.35	-0.15 to 0.85	0.17

The ß coefficient reflects the estimated difference in PROMIS score that would be expected for patients who presented during the COVID-19 pandemic compared with patients who presented before the COVID-19 pandemic, after adjusting for confounding variables. For example, patients from areas with a high Area Deprivation Index who presented to an orthopaedic provider during the COVID-19 pandemic would be expected to have a PROMIS Anxiety score of 0.84 points higher than that of patients who presented before the COVID-19 pandemic. Although this result is statistically significant (p < 0.05), a ß coefficient of 0.84 is less than the minimum clinically important difference value of 4 points, and therefore the result is interpreted as not clinically important. The other correlations evaluated in this table were neither statistically significant nor clinically important. High Area Deprivation Index denotes the most socially deprived quartile, whereas low Area Deprivation Index denotes the least socially deprived quartile. PROMIS = Patient-Reported Outcomes Measurement Information System.

Discussion

The COVID-19 pandemic presented a major challenge to our communities and healthcare system. Routine medical services were disrupted, economic activity was slowed, and personal well-being was threatened. Given the inter-relationship between psychosocial factors and functional outcomes in orthopaedic surgery [28], it is important that we understand whether the pandemic was associated with worse physical and mental health among patients presenting for orthopaedic care. In this study, we found no clinically important differences in baseline physical and mental health PROMIS scores between patients who initially presented to an orthopaedic provider before and during the COVID-19 pandemic. This finding was consistent across patients living in areas with high and low levels of social deprivation, even though patients living in areas with high levels of social deprivation had worse physical and mental health PROMIS scores than patients living in areas with low levels of social deprivation during both time periods. Although there appears not to be a need for greater mental health awareness or intervention for orthopaedic patients, we encourage continued mental and social health monitoring as new stressors arise in our society. Even in the absence of systemic changes, individual patients are likely adversely affected by pandemic-related stressors; therefore, it is necessary that orthopaedic providers remain cognizant of psychosocial health issues and advocate on behalf of patients when intervention is required.

Limitations

First, this study included only patients who presented to a single tertiary-care academic medical center in St. Louis, Missouri, and most patients were White non-Hispanic. These factors may limit the generalizability of our results to orthopaedic practices with more diverse patient populations, specifically those with larger Hispanic populations. Additionally, COVID-19 lockdown and social distancing policies varied substantially across state and local levels, and therefore our results may not reflect the health status of orthopaedic patients elsewhere in the United States. However, our study included 24,812 patients from 46 states, a wide range of ADIs, and a mix of insurance types. Notably, the highest ADI quartile was represented by nearly 2000 patients in each cohort and had a larger non-White population (approximately 37%) than the overall study population, and yet no clinically important differences in baseline PROMIS scores before and during the pandemic were observed in this group.

A second limitation to this study was that we excluded nearly 57% (32,591 of 57,043) of patients because of missing data for variables of interest. Although this might have introduced selection bias, to our knowledge, the missing data were not correlated with factors that would influence PROMIS scores, and the percentage of patients who were excluded was similar between the cohorts. Furthermore, we performed an exploratory analysis comparing demographic and PROMIS data between patients included in the study and those excluded from it and found no differences, which should add validity to our results.

Third, there may be selection bias among patients to pursue orthopaedic care during the pandemic. For example, patients with higher levels of anxiety or depression may have been more concerned about contracting a COVID-19 infection than their orthopaedic condition, and thus deferred their orthopaedic care. This would introduce some bias to our results and may have contributed to our negative findings.

Fourth, we did not track the physical or mental health status of individual patients over time (from before to during the pandemic), nor did we account for the impact of specific COVID-19-related factors (such as delays in medical care, social isolation, and financial loss) on patient health. Consequently, we cannot make any conclusions regarding the resilience or grit of our patient population. Future longitudinal studies are needed to examine how individual experiences with COVID-19-related stressors affected physical and mental health in orthopaedic patients.

Fifth, we captured the PROMIS scores of patients in the during COVID-19 cohort from initial visits in 2021, and therefore, the immediate and long-term postpandemic effects on the well-being of orthopaedic patients are not known. Additionally, we captured PROMIS scores from patients only at their initial presentation to a provider; therefore, it is unclear whether the pandemic influenced outcomes after orthopaedic treatment. Both of these questions should be addressed in future studies.

Lastly, we did not include telehealth visits in this study, because PROMIS computer adaptive tests were not administered during these visits. However, telehealth visits constituted a very small percentage of our overall practice during the study period, and we are not concerned that excluding these patients affected our findings.

Differences in PROMIS Scores Between Before and During the Pandemic

Patients seen during the COVID-19 pandemic demonstrated no clinically important differences in baseline PROMIS scores for physical function, pain interference, depression, or anxiety compared with patients seen before the pandemic. This was true across all orthopaedic subspecialties. At first glance, these results were surprising in light of studies demonstrating an increased prevalence of depression, anxiety, and post-traumatic stress disorder symptoms for the general population because of the pandemic [6, 8, 11, 23, 30]. However, a closer evaluation of previous studies revealed that much of this research was done using data collected during the early months of the pandemic, which contrasts with our study, which evaluated the PROMIS scores of patients during the pandemic in 2021. Indeed, a recent systematic review and meta-analysis of studies examining changes in mental health among United States adults before and during the pandemic found a small increase in mental health symptoms immediately after the outbreak that decreased and was comparable to prepandemic levels by mid-2020 [26, 27]. Similarly, an observational cross-sectional study of United States adult patients found nonclinically meaningful differences in PROMIS global physical health and PROMIS global mental health scores during the pandemic (August 2020) compared with 1 year earlier (August 2019) [18]. Additionally, a longitudinal observational study from the United Kingdom found high levels of depression and anxiety symptoms during early stages of the pandemic that declined to baseline levels thereafter [10]. It is therefore possible that orthopaedic patients in our practice experienced a similar trend in physical and mental health, with patients already recovered to prepandemic levels by 2021. Similar to our results, a cross-sectional study of patients with chronic pain presenting to a tertiary pain clinic in the California Bay area found that although pain catastrophizing scores were elevated when COVID-19 peaked in July 2020, physical function, pain interference, depression, and anxiety scores were either improved or unchanged compared with the pre-COVID-19 cohort [34]. The authors contributed these findings, in part, to patients in the post-COVID-19 cohort reporting increased access to emotional support and no worsening changes in social isolation and satisfaction with social roles. Although these findings may not be generalizable to other patient populations, it nevertheless highlights the importance of emotional support and social networks in promoting overall health and wellness. In our study, had we observed a clinically meaningful decline in physical or mental health among patients in the during COVID-19 cohort, perhaps we would be calling for preventative action to help mitigate its effects, including increased screening for pandemic-related stressors (such as exposure to infected individuals, loss of loved ones, social distancing, or economic insecurity) and psychosocial well-being (for example, anxiety, depression, psychologic distress, sleep disturbance, substance use, and domestic violence). Although systemic changes to screening protocol or policy may not be needed, it is likely that orthopaedic providers will continue to encounter individual patients who are adversely impacted by the direct or indirect effects of the pandemic; therefore, it is important that orthopaedic providers remain aware of the psychosocial needs of their patients and offer individualized support when necessary. This includes providing information about stress management and coping strategies, as well as emphasizing the importance of daily exercise, healthy eating, and sleep hygiene. Supporting patients emotionally and connecting them with social and mental health services when needed is important to ensure optimal functional outcomes after orthopaedic treatment.

Differences in PROMIS Scores Between Before and During the Pandemic Stratified by ADI

Despite having worse physical and mental health PROMIS scores than patients living in areas with low levels of social deprivation, patients living in areas with high levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the COVID-19 pandemic were compared. These results indicate that underlying disparities in the physical and mental health status of patients on initial presentation to an orthopaedic provider were not exacerbated since the onset of the pandemic. This was contrary to our expectations, because studies have indicated that not only is social deprivation a risk factor for COVID-19 infection and disease severity [20, 31, 32], but also that patients from communities with fewer socioeconomic resources were more vulnerable to the adverse physical and mental health effects of the pandemic [3, 16, 25]. One potential explanation for the discrepancy in results is that our study consisted of data collected from patients as part of routine clinical care and included only patients who had the self-agency to access specialty orthopaedic services at our institution, whereas the previously cited studies were not patient-specific and consisted of data collected from the general population for research purposes only. Additionally, a recent study found that patients with poorer overall health and lower household income were more likely to avoid medical care during the pandemic in 2021 [12], and therefore, our results might have underestimated the true change in the health status of orthopaedic patients from communities with high levels of social deprivation by not capturing those who avoided orthopaedic care. Efforts to identify patients who avoided orthopaedic care during the pandemic and ensure they are now receiving proper care may be warranted. A second potential explanation for our study results is that during the COVID-19 period, patients from areas with high levels of social deprivation were not disproportionately experiencing greater life disruptions than those from areas with low levels of social deprivation. Unfortunately, our study does not account for social or economic changes because of the pandemic; therefore, future studies are needed to draw a causal relationship between life disruptions from the pandemic and physical and mental health as it relates to patients presenting for orthopaedic care. A third potential explanation for our findings is that physical and mental health disparities because of the pandemic will not be fully appreciated until years after the pandemic’s onset. Indeed, a previous study found that acute socioeconomic decline after a natural disaster created long-term health disparities [17]. Although our study captured the PROMIS scores of patients during the pandemic at more than 1 year after its onset, future longitudinal studies are needed to determine the long-term health impact of the pandemic on patients presenting for orthopaedic care.

Conclusion

By using patient-reported outcomes, we demonstrated that the physical and mental health status of new patients presenting to an orthopaedic provider during the COVID-19 pandemic was not different from that of those who presented before the pandemic. This finding was consistent across patients living in areas with high and low levels of social deprivation. These results are encouraging in light of studies demonstrating worse physical and mental health for the general United States population, as well as for those from communities with fewer social and economic resources. As we continue to adapt to the pandemic or as new social and environmental stressors arise in our communities, it is important that orthopaedic providers continue to monitor the individual health status of their patients and identify those who may benefit from a mental health evaluation and treatment. In light of our results demonstrating continued disparities in baseline physical and mental health between patients residing in areas with high levels of social deprivation and those with low levels, research to identify strategies to improve the perceived health of patients residing in areas with fewer social and economic resources is warranted. Overall, our results should be interpreted in the context of our patient population (those receiving specialty orthopaedic care); therefore, future studies investigating the association or impact of the COVID-19 pandemic on patients from other medical specialties or clinical practices are needed. Additionally, future longitudinal studies evaluating the impact of specific COVID-19-related factors on orthopaedic outcomes may be helpful to prepare for future pandemics or natural disasters.