The Differential Effect of COVID on Total Joint Arthroplasty Between Hospital and Ambulatory Surgery Centers/Hospital Outpatient Departments: A Michigan Arthroplasty Registry Collaborative Quality Initiative Analysis.

Abstract

Coronavirus disease (COVID) created unprecedented challenges, especially for high-volume elective subspecialties like total joint arthroplasty. Limited inpatient capacity and resource conservation led to new outpatient selection criteria and site of service changes. As a Michigan Arthroplasty Registry Quality Collaborative Initiative quality project, demographic changes, complications, and differential effects on inpatient vs outpatient centers pre- and post-COVID were analyzed. The registry identified all total joint arthroplasty at hospitals and ASCs/HOPDs between 07/2019-12/2019 and 07/2020-12/2020. These intervals represented pre-COVID and post-COVID elective surgery shutdowns. Case volumes, demographics, and 90-day complications were compared. Comparing 2020 to 2019, hospital volumes decreased (-9% total hip arthroplasty [THA],-17% total knee arthroplasty [TKA]), and ambulatory surgery center (ASC)/hospital outpatient department (HOPD) increased (+84% THA,+125% TKA). Entering 2020, ASC/HOPD patients were older (P= .0031, P < .0001: THA, TKA), had more American Society of Anesthesiologists score 3-4 (P= .0105, P= .0021), fewer attended joint class (P < .0001, P < .0001), and more hips were women (P= .023). Hospital patients had higher preoperative pain scores (P= .0117, P < .0001; THA, TKA), less joint education attendance (P < .0001, P < .0001), younger TKAs (P= .0169), and more American Society of Anesthesiologists score 3-4 (0.0009). After propensity matching, there were no significant differences between site of service for 90-day fractures, deep vein thromboses or pulmonary embolisms, infection, or hip dislocations. Hospital THAs had higher readmissions (P= .0003) and TKAs had higher 30-day emergency department visits (P= .005). ASC/HOPD patients were prescribed higher oral morphine equivalents (P < .0001, P < .0001; THA, TKA). COVID's elective surgery shutdown caused a dramatic site of service shift. Traditional preoperative education was negatively impacted, and older and sicker patients became outpatients. But short-term complications were not increased in ASCs/HOPDs. These site of service and associated patient demographic changes may be safely sustained.