Is it safe yet? Patient readiness and perceptions about returning to hospital for planned orthopaedic care

Abstract

Introduction

COVID-19 has necessitated significant changes to healthcare delivery but little is known regarding patient opinions of risks compared with benefits. This study investigates patient perceptions concerning attendance for planned orthopaedic surgery during the COVID-19 pandemic.

Materials and methods

A total of 250 adult patients from the elective orthopaedic waiting list at Cardiff and Vale University Health Board were telephoned during lockdown. They were risk stratified for COVID-19 based on British Orthopaedic Association guidance and a discussion was held to determine patient willingness to proceed with surgery. The primary outcome measure was patients’ willingness to proceed.

Results

Of the total number telephoned, 196 patients were included in the study, with a mean age of 57.4 years; 129 patients were willing to attend for surgery, leaving over one-third wishing to cancel or defer. The most frequent reason given for not wishing to attend was fear of contracting COVID-19. There was a statistically significant difference in the willingness to proceed observed with increasing clinical risk (χ²(3) = 50.073, p = .000) with almost double the expected count of unwilling to proceed in the high and very high risk groups, equalled by half the expected count in the low risk group.

Discussion

This study illustrates the variable and personal decisions that patients are making about orthopaedic care because of COVID-19. It highlights the need for change to departmental processes regarding recommencement of planned surgical lists. It also reconfirms the importance of regular communication and shared decision making between a well-informed patient and a holistic orthopaedic team.

Introduction

The impact of COVID-19 has been well documented and has necessitated significant changes to the delivery of planned and emergency care across the globe.^1–5 The landscape of the NHS changed dramatically overnight: planned surgical services were cancelled, departments restructured and staff redeployed to combat the pandemic. While the situation remains changeable and the future uncertain, the lockdown is gradually being eased and the focus changes from damage control to reinstating a more normal orthopaedic practice.

Numerous criteria have been recommended for the recommencement of planned surgical care.^6–8 These focus on establishing COVID-free zones, termed ‘green zones’, where the risk of COVID-19 transmission can be minimised as effectively as possible. A key component of these streams is a preoperative two-week self-isolation and negative COVID-19 swab within 72 hours of admission.

In the UK, there has been unprecedented publicity surrounding the novel coronavirus and its detrimental impact on the NHS. The public are perhaps more aware than ever of the essential role that the NHS plays and the limitations it faces.^9–14 There has been a recognised reluctance for patients to attend hospital, even when experiencing life-threatening conditions, and there is no published literature concerning patient perceptions or whether patients wish to visit hospital for surgery in the present COVID-19 climate.^15–18

The current published guidance indicates that certain comorbidities represent a greater risk from COVID-19. Increased age, diabetes, chronic respiratory disease, including asthma, chronic kidney disease, immunocompromise, severe obesity and liver dysfunction all contribute to an increased risk of poor outcome or death following COVID-19 infection.^6,19 Patients with these comorbidities, who were previously considered medically fit for orthopaedic surgery, now fall into higher risk groups, significantly changing the risk–benefit balance of surgery for them.

Before widespread reorganisation and implementation of planned orthopaedic care can commence, we must recognise that the fear around COVID-19 may inadvertently prevent service delivery to those in need, regardless of the safety measures implemented. We describe how we sought to determine patient perceptions concerning hospital attendance and medical risk profiles for patients awaiting planned orthopaedic surgery in an ever-changing COVID-19 landscape. We hypothesised that a significant proportion of patients currently listed for surgery would not want to attend in the current climate and this study aimed to quantify that proportion. Secondary outcomes were to investigate the effect of risk level on decision making, the reasons behind not wishing to attend and whether the attendance rate differed between the different subspecialties of orthopaedics.

Materials and methods

A COVID-19 screening tool was created based upon the British Orthopaedic Association (BOA) guidance on restarting non-urgent trauma and orthopaedic care.⁶ This tool contains details of patient demographics, proposed procedure, type of anaesthetic, patients’ wishes regarding proceeding or deferring surgery, the clinical risk category and the consultants’ risk–benefit analysis. The screening tool has become a core component of our novel post-COVID-19 preoperative pathway and remains in the patient’s records.

Split subspecialty waiting lists were used to identify 250 adult patients (aged over 18 years) awaiting planned orthopaedic care within the Cardiff and Vale University Health Board, equally drawn from the hand and wrist, knee, foot and ankle, shoulder and elbow, and hip surgical teams. Patients under all consultants within these specialties were included. This study was part of a wider waiting list validation exercise and all patients on the waiting list will be contacted and stratified using the same screening tool over the coming months.

Attempted contact with all patients via their registered telephone number was made between 25 May 2020 and 3 June 2020 by the surgical team. Two attempts at contact were made on consecutive days to all listed telephone numbers, before the patient was recorded as being uncontactable. These patients will be invited by post to a face-to-face review once clinics are restarted.

After an introductory description of the current situation and the need to plan for a safe return to elective surgery, patients underwent the medical screening questionnaire to ascertain age and to identify the relevant comorbidities of asthma, chronic lung disease, diabetes, serious heart conditions, chronic kidney disease, severe obesity, immunocompromise and liver disease, and were subsequently categorised into one of four clinical risk categories (Table 1).⁶ Following this, a discussion to determine the patients’ willingness to proceed with surgery, defer or cancel entirely was undertaken. Those who chose to decline or defer surgery were offered the opportunity to discuss their reasoning to determine the likelihood of change in the future. Closed questioning to refine the reasoning ensured that data collection was speedy and the questions easy to answer. The analysis was punctual and the communication skills of our interviewed patients was less critical.^20,21

Table 1 .

British Orthopaedic Association clinical risk categories⁶

Clinical risk category	Patients included
Low	< 65 years with no risk factors
Medium	> 65 years with no risk factors
	< 65 years with 1 risk factor
High	> 65 years with 1 risk factor
	< 65 years with 2 risk factors
Very high	All with 3 or more risk factors

To avoid pressurising patients towards a decision and to ensure that the process was as informed as the current knowledge base allowed, the following points were highlighted during the discussion:

• •Their clinical risk category and the probable outcome should they contract COVID-19. It was emphasised that the risk of contracting the virus in hospital is currently uncertain but appears to be low.
• •All reasonable steps to minimise the risk of transmission would be undertaken, but there was a risk of contracting COVID-19 during any hospital attendance.
• •When a patient decided to proceed with surgery, they would have to self-isolate for a period of 14 days prior to the operation. If they could not isolate from other members of the household then everyone would have to isolate. Where necessary, patients were directed to the government’s guidelines for the definition of self-isolation.²²
• •The patient would then be required to undertake a COVID-19 throat swab approximately 48–72 hours before surgery. If the test was negative, their procedure would go ahead.
• •Finally, patients were reassured that should they chose not to proceed with surgery, their decision could be reversed at any time without affecting their place on the waiting list.

Statistical analysis was performed using SPSS Version 25. Normality of age (the only continuous variable) was determined using the Shapiro–Wilks test for normality. Age was not normally distributed therefore non-parametric analyses of the age data were performed using both Mann–Whitney U and Kruskal–Wallis tests. Chi square and Fisher’s exact tests were used to assess expected frequencies.²³

Results

A total of 250 patients were identified from the ‘top’ of the planned orthopaedic waiting list: 50 from each subspecialty; hand and wrist, knee, shoulder and elbow, foot and ankle, and hip surgery. Despite two telephone calls, 53 patients were uncontactable and were excluded from further analysis. One patient (listed for an urgent knee arthroscopy) was aged 12 years and was also excluded. One patient who was on the foot and ankle waiting list and awaiting a rotational femoral osteotomy was analysed in the foot and ankle cohort. The remaining 196 patients were contacted by telephone and completed the screening tool over the phone. The median age was 59.8 years (range 19.3–89.9 years). There was a statistically significant difference (Kruskal–Wallis test, p = .000) in the mean ages between the subspecialty waiting lists (Table 2).

Table 2 .

Breakdown of patients included in the study

Subspecialty	Patients included (n)	Mean age (years)
Hand and wrist	46	60.9
Knee	37	54.4
Shoulder and elbow	32	50.6
Foot and ankle	36	46.3
Hip	45	69.8
Total	196	57.4

All patients were categorised using the BOA clinical risk tool.⁶ Following a discussion concerning the perceived risks, patients were asked whether they would attend a consent clinic, be prepared to self-isolate and undergo a COVID-19 swab prior to surgery. There was a statistically significant difference in the willingness to proceed observed with increasing clinical risk (χ²(3) = 50.073, p = .000) with almost double the expected count of those unwilling to proceed in the high and very high risk groups, equalled by half the expected count in the low risk group (Table 3). Of the 129 patients willing to consider attending hospital for surgery, 59% were in a low-risk category (Table 3).

Table 3 .

Patient willingness to proceed with surgery by clinical risk group and subspecialty

Subspecialty	Clinical risk category	Patients willing to proceed					Total
		No			Yes
		(n)	(%)		(n)	(%)
Hand and wrist	Low	4	23.5		13	76.5	17
	Medium	4	30.8		9	69.2	13
	High	11	91.7		1	8.3	12
	Very high	3	75		1	25	4
	Total	22	47.8		24	52.2	46
Knee	Low	1	5.3		18	94.7	19
	Medium	5	38.5		8	61.5	13
	High	1	25		3	75	4
	Very high	0	0		1	100	1
	Total	7	18.9		30	81.1	37
Shoulder and elbow	Low	0	0		21	100	21
	Medium	2	50		2	50	4
	High	4	66.7		2	33.3	6
	Very high	1	100		0	0	1
	Total	7	21.9		25	78.1	32
Foot and ankle	Low	6	16.7		15	71.4	21
	Medium	4	36.4		7	63.6	11
	High	3	100		0	0	3
	Very high	0	0		1	100	1
	Total	13	36.1		23	63.9	36
Hip	Low	2	18.2		9	81.8	11
	Medium	5	23.8		16	76.2	21
	High	7	87.5		1	12.5	8
	Very high	4	80		1	20	5
	Total	18	40		27	60	45
Totala	Low	13	14.6		76	85.4	89
	Medium	20	32.3		42	67.7	62
	High	26	78.8		7	21.2	33
	Very high	8	66.7		4	33.3	12
	Total	67	34.2		129	65.8	196

^a Chi square 50.073, df = 3, p = .000

There was a statistically significant difference between individual subspecialty cohorts, with fewer than expected patients willing to proceed with hand and wrist or hip surgery and more than expected willing to proceed with knee and foot and ankle surgery (P < .05) (Table 3). There was a mean difference in age between patients willing to proceed (mean age 52.9 years) and those that were not (mean age 65.9 years; Mann–Whitney U test, p = .000) and between the clinical risk groups, with the higher risk groups having a greater mean age (Kruskal–Wallis test, p = .000; Table 4).

Table 4 .

Mean age by clinical risk category

Clinical risk category	Mean age (years)
Low	43.4
Medium	67.6
High	69.8
Very high	74.0

A variety of reasons were given by those patients unwilling to proceed with surgery, with fear of contracting the COVID-19 virus being the most common, cited by 49 patients (Table 5). A minority of patients were undergoing or awaiting investigation for other medical conditions – usually suspected cancer.

Table 5 .

Reasons given by patients unwilling to proceed with surgery

Subspecialty	Fear of contracting COVID-19	Risk of transmission to others	Symptoms did not warrant risk	Carer responsibilities	Work issues	Unable to self-isolate	Other medical conditions
Hand and wrist	18	2	6	3	2	2	2
Knee	5	4	1	0	1	1	0
Shoulder and elbow	6	4	3	2	0	0	1
Foot and ankle	8	4	4	1	2	2	0
Hip	12	8	7	2	1	1	1
Total	49	22	21	8	6	6	4

Discussion

Over one-third of patients are currently unwilling to attend hospital for planned orthopaedic surgery due to the COVID-19 pandemic. Fear of contracting the virus was the most common reason and was cited by 73% of patients unwilling to proceed with surgery. However, it was common for patients to give more than one reason reflecting the multiple potential barriers to surgery.

The proportion deciding to delay surgery varied between subspecialty. Subspecialties with an older mean age had a higher proportion of patients who did not want to proceed with their operations. It is possible that unwillingness (or decision not to proceed with surgery at this time) to proceed with surgery at this time is related to the age of the cohort rather than the subspecialty.

Within the context of a constantly evolving national and global situation, it is likely that patients’ assessment of their individual risk will change. This study was conducted while Wales was still in lockdown. Attitude towards risk and the willingness to attend hospital is likely to change as our understanding of the risks improves with the gradual ease of lockdown. We anticipate that more information will be available for decision making and consent which will influence the uptake of planned surgery.

The telephone screening highlighted the very personal nature of the new risk–benefit analysis that will be necessary for every surgical procedure. While the telephone screening was conducted prior to the publication of surgical outcomes by the COVIDSurg Collaborative,²⁴ it was explained to all patients that COVID-19 infection could be associated with death in patients at higher risk. Despite this, a subgroup of patients felt that their musculoskeletal symptoms were sufficiently severe that they wanted to proceed with surgery. Patients at a lower risk wished for prompt surgery, often to minimise further disruption to their employment/income this year. Unsurprisingly, many expressed a wish to delay making a definite decision until more information was available.

It was noticeable that many patients took time to express their gratitude for both the call and the general work of the hospital and the wider NHS. Patients were glad to be reassured that they had not been forgotten. The calls were universally met with a positive response. There was an acceptance of this unprecedented situation and the delay being entirely outside of the hospital’s control.

As more becomes known about the coronavirus, the risk assessment itself will have to change. The COVID-19 screening tool does not replace the importance of a thorough history and personalised risk assessment to inform shared decision making. We await further information as more detailed analysis of risk factors such as ethnicity becomes available.^25,26 This will need to be carefully implemented to mitigate any detrimental effects on equal access to healthcare.

Our results are a guide to the likely take-up of operations as planned surgery is reintroduced. How surgical prioritisation and provision is structured will vary depending on the surgical environment unique to each hospital. We suggest that telephone communication should be the first step, ideally from a senior clinician. A clear description of the uncertainties around COVID-19 transmission, the novel preoperative pathways, including self-isolation, and an individualised appraisal of the risk-benefit balance should be considered for each patient awaiting surgery. Patients should be given time to absorb the information and be offered a later call for further discussion. A shared decision can then be reached. It is paramount that patients are reassured that deferment will not cause them to be removed from the waiting list. Thus, a strategy should be established to reassess these patients in a timely manner for suitability. The fear of abandonment was a source of anxiety for several patents. For patients willing to proceed, final consent should be obtained, ideally from their lead clinician.

It is apparent that patients in the greatest need and most likely to benefit from prompt orthopaedic surgical treatment, are also in the highest risk categories. It will be difficult to overcome this juxtaposition. To maximise the clinical efficiency of the new normal surgical services, the balance of treating the urgent patients first or treating the safest patients first will need to be considered. The current outlook for patients in the highest risk groups is uncertain. Careful and detailed consent, with access to up-to-date information concerning risk of COVID-19 transmission and clinical outcomes, will be essential in the shared decision making for this group. For high-risk patients awaiting non-essential surgery for non-painful conditions, the risks of surgery in the post-COVID-19 era are likely to outweigh the benefits. For these patients, a careful reconsidering of the decision for surgery may be needed.

The undercurrent of anxiety cannot be understated. Whether it is through fear of contracting the virus, passing it on to a loved one or the logistical issues with mandatory self-isolation, instigating planned surgery will require delicate navigation. Those in pain are currently stuck between maintaining their status quo or running the gauntlet of coming into hospital and accepting the unquantifiable risk of contracting COVID-19. Our results add to the current literature in what is uncharted territory for all surgical specialties. By understanding the apprehensions of those we wish to help, we can move forward and provide targeted efforts to alleviate those fears allowing a safe return of service in a landscape that seems likely to remain uncertain and changeable for the foreseeable future.

This study is limited by its purely observational design using novel routine data. A qualitative study design, probing deeper into the patient decision making process would offer rich data to accompany our findings. However, the rapidly changing landscape of COVID-19 could inadvertently influence data collection as opinions change with time and greater understanding and publicity surrounding the virus. We considered that the quantification of the lower than expected uptake of planned surgical services and the broad reasoning behind that – both clinical risk and patient preference – was a sufficiently important finding in isolation.

Conclusion

This study illustrates the very variable and personal decisions that patients are making regarding their orthopaedic care because of COVID-19. It highlights the need for radical change to the departmental processes regarding patient prioritisation and the recommencement of planned surgical lists. However, it also reconfirms the vital importance of regular communication and shared decision making between a well-informed patient and a holistic orthopaedic team. We also believe that undertaking a process such as this is important and relevant for all medical teams as they plan for the resumption of their services.