CORR Insights®: What is the Impact of the COVID-19 Pandemic on Quality of Life and Other Patient-reported Outcomes? An Analysis of the Hand-Wrist Study Cohort

Where Are We Now?

The global coronavirus 2019 (COVID-19) outbreak has led to an abundance of research on the negative short-term and long-term effects of the virus on its victims, including a range of long-term neurologic, cardiovascular, and mental-health sequalae [5, 8]. Research has also documented the impact of the threat of infection and subsequent lockdown and social distancing protocols on mental health, with research showing an increased prevalence of depression and anxiety in the general population [3, 8]. Similarly, across medical settings, we have seen a decrease in emergency room visits, with patients presenting with advanced stages of stroke, myocardial infarction, or other major illnesses [4] for fear of becoming infected during a medical visit.

In this issue of Clinical Orthopaedics and Related Research®, Cohen et al. [2] used data from a large, ongoing hand and wrist study across 28 clinics in the Netherlands to explore whether the COVID-19 lockdown influenced patient-reported outcomes of quality of life, pain, hand function, anxiety, depression, and illness perception. Specifically, they compared responses at 3, 6, and 12 months posttreatment between patients in the pre-COVID-19 era (2018 through 2019) and those in the early post-COVID-19 era (March 2020 through May 2020). The authors [2] found no between-group differences in quality of life, hand function, anxiety, or depression. Furthermore, lower pain and illness perception were observed in the COVID-19 cohort than in the pre-COVID-19 group, although the authors noted that these differences are likely not clinically important. This was unexpected. The topic is important because it has implications for the treatment of patients during the current pandemic, as well as for future global crises that may require similar restrictions, including changes in individual and medical care routines.

Where Do We Need To Go?

The results of this study [2] provide opportunities for three main areas of future research. First, it will be important to see whether the findings of this study, which was conducted early in the lockdown, would remain constant over the prolonged pandemic, or whether quality of life during COVID-19 would worsen. This is important because prior research shows that there has been an increase in the level of COVID-19-related mental health concerns over time [6], similar to what we have seen during the severe acute respiratory syndrome epidemic [1]. Second, it will essential to understand whether findings from Netherlands apply globally to countries with different lockdown policies and restrictions. The Dutch lockdown procedures were implemented early and with safer guidelines and better consequences than in other countries including the United States. The number of COVID-19-related deaths in the Netherlands was relatively low, there were no shortages of beds in intensive care units, and the lockdown was not as restrictive as in other parts of the world [7]. While in the Netherlands the mental health of individuals in May 2020 was roughly the same as that of individuals 6 months earlier [7], in the United States, the prevalence of depression symptoms was three-fold higher in March and April 2020 than it was before COVID-19 [8]. Third, the authors benefited from a large cohort study, which allowed them to make comparisons using the same measures administered before and after the COVID-19 pandemic. Future studies should expand on this work to help us understand which patients might have been more negatively affected. We know that a history of poor mental health or a history of adverse childhood events is associated with more-challenging adjustment to general life events, including the pandemic. The advantage of large samples is that we can have more confidence in results at the population level. The disadvantage is that we can miss important outliers who provide important information on the group of people who suffer.

How Do We Get There?

Cohen et al.’s [2] article offers a message of hope. Pandemics do not have to be associated with negative mental-health outcomes. An intelligent lockdown as was done in the Netherlands did not, at least in the short-term, produce negative mental health and quality of life consequences in patients suffering from hand conditions. This finding has important implications for healthcare policy globally, particularly if findings are replicated in the Netherlands with longer follow-up durations and across medical conditions. Additionally, head-to-head comparisons of patients from different countries would be extremely important to fully understand how and why lockdown and physical distancing policies differently impact patient outcomes. Lastly, analyses of risk and resiliency factors associated with maintaining good quality of life and mental health over time would be important to study. It will be important to identify participants who perhaps did not maintain good quality of life and mental health, as well as identify factors associated with this trajectory. My suspicion is that the common suspects of catastrophic thinking and low self-efficacy, which are typically drivers of poor mental health and quality of life in this population, are further magnified by the pandemic. Identifying this subset of patients early on provides an important opportunity to intervene not only to help them adjust to their orthopaedic condition but also to help prevent a rollercoaster of negative mental-health consequences.