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Comparison of total joint arthroplasty care patterns prior to the Covid-19 pandemic and after resumption of elective surgery during the Covid-19 Outbreak: A retrospective, large urban academic center study

      Abstract

      Background

      After the suspension of elective surgeries was lifted in June 2020 in New York State, challenges remained regarding coordination of total joint arthroplasty (TJA) cases. Using the experience from a high-volume health system in New York City, we aimed to describe patterns of care after resumption of elective TJA.

      Methods

      We retrospectively assessed 7,699 TJAs performed before and during the COVID-19 pandemic. Perioperative characteristics and clinical outcomes were compared between TJAs based on time period of performance: 1) pre-pandemic (PP, June 8th–December 8th, 2019), 2) initial period post-resumption of elective surgeries (IR, June 8th–September 8th, 2020), and 3) later period post-resumption (LR, September 9th–December 8th, 2020).

      Results

      LOS > 2 days (83%, 67%, 70% for PP, IR, LR periods respectively) and discharge rates to post-acute care (PAC) facilities were lower during the pandemic periods (ORIR vs. PP: 0.48, 95% CI: 0.40–0.59, p < 0.001; ORLR vs. PP: 0.63, 95% CI: 0.53–0.75, p < 0.001). Compared to the pre-pandemic period, the risk for 30-day readmission was lower during the IR period (OR: 0.62, 95% CI: 0.40–0.98, p = 0.041) and similar during the LR period (OR: 0.96, 95% CI: 0.65–1.41, p = 0.832).

      Conclusions

      Despite decreased LOS and discharge to PAC for TJAs performed during the pandemic, 30-day readmissions did not increase. Given the increased costs and lack of superior functional outcomes associated with discharge to PAC, these findings suggest that discharge to PAC facilities need not return to pre-pandemic levels.

      Keywords

      1. Introduction

      Formally declared a pandemic on March 11, 2020 by the World Health Organization, COVID-19 has contributed to over 212 million confirmed cases and 4.4 million deaths worldwide as of August 25, 2021 [
      • O’Connor C.M.
      • Anoushiravani A.A.
      • DiCaprio M.R.
      • Healy W.L.
      • Iorio R.
      Economic Recovery After the COVID-19 Pandemic: Resuming Elective Orthopedic Surgery and Total Joint Arthroplasty.
      ,
      • Kalakoti P.
      • Gao Y.
      • Hendrickson N.R.
      • Pugely A.J.
      Preparing for Bundled Payments in Cervical Spine Surgery: Do We Understand the Influence of Patient, Hospital, and Procedural Factors on the Cost and Length of Stay?.
      ]. Within the months of March and April 2020, New York State, and New York City in particular, quickly became an epicenter for the COVID-19 outbreak [
      • Zachariah P.
      • Johnson C.L.
      • Halabi K.C.
      • Ahn D.
      • Sen A.I.
      • Fischer A.
      • et al.
      Epidemiology, Clinical Features, and Disease Severity in Patients With Coronavirus Disease 2019 (COVID-19) in a Children’s Hospital in New York City, New York.
      ,
      • Mikami T.
      • Miyashita H.
      • Yamada T.
      • Harrington M.
      • Steinberg D.
      • Dunn A.
      • et al.
      Risk Factors for Mortality in Patients with COVID-19 in New York City.
      ]. Recommendations to cancel elective procedures were soon issued by the United States Surgeon General and American Association of Hip and Knee Surgeons (AAHKS) [
      • Rizkalla J.M.
      • Gladnick B.P.
      • Bhimani A.A.
      • Wood D.S.
      • Kitziger K.J.
      • Peters Jr., P.C.
      Triaging Total Hip Arthroplasty During the COVID-19 Pandemic.
      ]. Total hip and knee joint arthroplasty (TJA), two of the most common orthopedic elective procedures, were among the cohort of elective surgeries that were suspended in mid-March 2020 across New York State [
      • Wilson J.M.
      • Schwartz A.M.
      • Farley K.X.
      • Roberson J.R.
      • Bradbury T.L.
      • Guild G.N.
      Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19.
      ,
      • Poeran J.
      • Zhong H.
      • Wilson L.
      • Liu J.
      • Memtsoudis S.G.
      Cancellation of Elective Surgery and Intensive Care Unit Capacity in New York State: A Retrospective Cohort Analysis.
      ].
      Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are widely regarded as highly successful procedures, as numerous studies have outlined both their cost-effectiveness and societal benefits [
      • Koenig L.
      • Zhang Q.
      • Austin M.S.
      • Demiralp B.
      • Fehring T.K.
      • Feng C.
      • et al.
      Estimating the Societal Benefits of THA After Accounting for Work Status and Productivity: A Markov Model Approach.
      ,
      • Bedair H.
      • Cha T.D.
      • Hansen V.J.
      Economic benefit to society at large of total knee arthroplasty in younger patients: a Markov analysis.
      ]. With cancellations of elective TJA across the country, researchers have estimated that over 300,000 TJA procedures were delayed through June 2020 [
      • Wilson J.M.
      • Schwartz A.M.
      • Farley K.X.
      • Roberson J.R.
      • Bradbury T.L.
      • Guild G.N.
      Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19.
      ]. For New York City in particular, elective surgeries did not resume until June 8th, 2020 [
      • Farcy J.P.
      • Schwab F.J.
      Management of flatback and related kyphotic decompensation syndromes.
      ]. Given that about 1.4 million TJA procedures were projected to be performed in 2020, the suspension and resulting delay of these procedures is suspected to cause severe financial strain for hospital systems across the country [
      • Jella T.K.
      • Samuel L.T.
      • Acuña A.J.
      • Emara A.K.
      • Kamath A.F.
      Rapid Decline in Online Search Queries for Hip and Knee Arthroplasties Concurrent With the COVID-19 Pandemic.
      ]. Additionally, the backlog in TJA procedures poses specific challenges regarding triaging surgical cases, coordinating with institutional post-acute care, and evaluating effects on provider reimbursement. Thus, the purpose of this study is to characterize and compare patterns of care for TJA after the resumption of elective surgery.

      2. Materials and methods

      This study was approved by the Institutional Review Board. A retrospective medical record review was performed to determine the two study populations of interest: 1) patients who underwent total joint arthroplasty (TJA) between June 8th–December 8th 2019, and 2) June 8th–December 8th 2020. TJA was defined as the sum of total knee arthroplasty (TKA) and total hip arthroplasty (THA) cases performed during these selected time periods. Patients who underwent TKA and patients who underwent THA across an urban, academic health system were identified. Additional inclusion criteria included age greater than or equal to 18 years, elective surgery, and inpatient surgery. Patients who died during hospitalization or underwent nonelective procedures were excluded. Out of 11,459 TJA patients, 7,699 patients met our inclusion and exclusion criteria for this study.
      TJA cases were divided into three groups based on time period of performance: 1) pre-pandemic (PP; procedures performed from June 8th–December 8th, 2019), 2) initial-resumption (IR; procedures performed during the pandemic directly after the resumption of elective surgery in NYC, June 8th–September 8th, 2020), and later-resumption (LR; procedures that occurred greater than 3 months after the resumption of elective surgery in NYC, September 9th–December 8th, 2020). Covariates pertaining to patient characteristics were collected for each group: age (median, <65, 65), sex (% male), BMI (<18, 18–29, 30), race (white, non-white), location (patient residence in NYC, patient residence not in NYC), Charlson Comorbidity Index (CCI) (0, 1, ≥2), American Society of Anesthesiologists (ASA) score (1, 2, ≥3) [
      • Quan H.
      • Sundararajan V.
      • Halfon P.
      • Fong A.
      • Burnand B.
      • Luthi J.-C.
      • et al.
      Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
      ]. Surgical care patterns were also collected for each group: anesthesia type (regional, general), operative time, length of stay (LOS; median, ≤2 days, > 2 days), frequency of blood transfusion, readmission rate within 30 days, and discharge patterns (home, institutional post-acute care [PAC]).
      Univariable associations were assessed using standardized differences instead of p-values given the large sample size. A standardized difference (STD) of 0.1 (or 10%) has been previously proposed to indicate a meaningful difference between groups, and was thus used [
      • Austin P.C.
      An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies.
      ]. For each variable, comparisons were made between the following cohorts: 1) pre-pandemic & initial-resumption, 2) pre-pandemic & later-resumption, 3) initial-resumption & later-resumption. Multivariable logistic regression models controlling for age, sex, race, BMI, anesthesia type, CCI, ASA score, and TJA type (THA or TKA) were used to assess associations between TJA time periods and the following outcomes: length of stay > 2 days, discharge to institutional post-acute care, and 30-day readmissions. All of these analyses were performed in SAS v9.4 statistical software (SAS Institute, Cary, NC).

      3. Results

      A summary of patient characteristics is provided in Table 1. A total of 7,699 patients who underwent TJA (THA or TKA) were included in this study, with 4,221 procedures performed in the pre-pandemic period, 1,629 procedures performed between in the initial resumption period, and 1,849 procedures performed in the period following initial resumption. The median age of TJA patients was highest in the pre-pandemic period (66.56 years), as the median ages were 65.14 years (STD = 0.180) and 64.97 years (STD = 0.125) during the initial resumption and later-resumption periods respectively. The percentage of male TJA patients was greater during the initial resumption period, as males accounted for 32.62% of cases prior to the pandemic and 39.29% in the initial resumption period (STD = 0.139).
      Table 1Patient Characteristics.
      VariablesPre-Pandemic TJAs (n = 4,221)Initial Resumption TJAs (n = 1,629)Later Resumption TJAs (n = 1,849)Standardized Difference (PP vs. IR)Standardized Difference (PP vs. LR)Standardized Difference (IR vs. LR)
      Age
      Median (years)66.56 (59.51–73.88)65.14 (58.60–72.02)64.97 (59.22–72.13)0.1800.1250.058
      Categorical0.1050.1150.012
      652345 (55.56%)820 (50.34%)921 (49.81%)
      <651876 (44.44%)809 (49.66%)928 (50.19%)
      Sex- Male0.1390.0590.080
      Yes1377 (32.62%)640 (39.29%)655 (35.42%)
      No2844 (67.38%)989 (60.71%)1194 (64.58%)
      BMI
      Medians30.11 (26.37–34.46)30.27 (26.13–34.78)29.95 (26.07–34.67)0.0340.0130.047
      Categorical0.1930.2890.145
      <18174 (4.12%)12 (0.74%)6 (0.32%)
      18–301982 (46.96%)780 (47.88%)922 (49.86%)
      >302065 (48.92%)837 (51.38%)921 (49.81%)
      Race0.0990.0060.105
      White1755 (41.58%)757 (46.47%)763 (41.27%)
      Non-White2466 (58.42%)872 (53.53%)1086 (58.73%)
      Location0.0820.1170.035
      NYC residence2866 (67.9%)1043 (64.03%)1153 (62.36%)
      non-NYC residence1355 (32.1%)586 (35.97%)696 (37.64%)
      CCI0.0820.0540.048
      02321 (54.99%)957 (58.75%)1052 (56.9%)
      11106 (26.2%)383 (23.51%)473 (25.58%)
      ≥2792 (18.76%)289 (17.74%)324 (17.52%)
      Unknown2 (0.05%)0 (0.00%)0 (0.00%)
      ASA0.1220.1750.089
      156 (1.35%)14 (0.89%)30 (1.73%)
      22164 (52.36%)918 (58.43%)1022 (58.9%)
      ≥31913 (46.29%)639 (40.67%)683 (39.37%)
      Unknown8858114
      There was a nearly significant difference in patient race between the pre-pandemic (% of non-white patients: 58.42%) and initial resumption periods (% of non-white patients: 53.53%) (STD = 0.099). There was no significant difference in patient race between the pre-pandemic and later-resumption periods (% of non-white patients: 58.73%) (STD = 0.006). There was a significant difference in patient race between the initial-resumption (% of non-white patients: 53.53%) and later-resumption time (% of non-white patients: 58.73%) periods (STD = 0.105). While there was no difference in median BMI across the three time periods (none of the standardized differences are > 0.1), fewer patients with BMI < 18 were operated on during the COVID-19 pandemic (% of BMI < 18 patients: pre-pandemic = 4.12%, initial-resumption = 0.74% (STD = 0.193), later-resumption = 0.32% (STD = 0.289)).
      There was no significant difference in Charlson Comorbidity Index scores between patients in all three cohorts (none of the standardized differences are > 0.1). ASA scores were lower for patients whose TJAs were performed during the pandemic, as the percentage of patients with ASA ≥ 3 was 46.29% prior to the pandemic, 40.67% in the initial resumption period (STD = 0.122), and 39.37% in the later-resumption period (STD = 0.175). There was no significant difference in ASA scores between the initial-resumption and later-resumption cohorts (STD = 0.089).
      A summary of surgical care pattern data is provided in Table 2. There was no difference in OR time, blood transfusions, and type of anesthesia used for cases performed prior to and during the pandemic (none of the standardized differences are > 0.1). Patients who underwent TJAs during the pandemic had shorter LOS, as the median LOS was 2.35 days prior to the pandemic, 2.26 days in the initial period (STD = 0.233), and 2.25 days in the later period (STD = 0.190). There was no difference in median LOS between the initial resumption and later-resumption periods (STD = 0.039). On categorical analysis, 82.50% of patients had a LOS > 2 days during the pre-pandemic period, while only 67.1% of patients in the initial-resumption period (STD = 0.360) and 70.4% of patients in the later-resumption period (STD = 0.288) had a LOS > 2 days.
      Table 2Surgical Care Patterns.
      Pre-Pandemic TJAs (n = 4,221)Initial Resumption TJAs (n = 1,629)Later Resumption TJAs (n = 1,849)Standardized Difference (PP vs. IR)Standardized Difference (PP vs. LR)Standardized Difference (IR vs. LR)
      Anesthesia0.0280.0430.071
      Regional3928 (93.06%)1504 (92.33%)1740 (94.1%)
      General293 (6.94%)125 (7.67%)109 (5.9%)
      L.O.S. median (days)2.35 (2.16–3.28)2.26 (1.40–3.11)2.25 (1.46–3.04)0.2330.1900.039
      L.O.S categorical0.3600.2880.071
      ≤2 days740 (17.50%)536 (32.9%)548 (29.6%)
      >2 days3481 (82.50%)1093 (67.1%)1301 (70.4%)
      OR time median (minutes)166 (146–189)164 (147–183)167 (148–188)0.0770.0360.049
      Blood Transfusion (%)102 (2.42%)32 (1.96%)61 (3.30%)0.0310.0530.084
      Readmission within 30 days116 (2.76%)24 (1.47%)45 (2.44%)0.090.020.07
      Discharge to Institutional Post-Acute Care?0.3010.2240.078
      Yes840 (19.9%)153 (9.39%)218 (11.79%)
      No3381 (80.1%)1476 (90.61%)1631 (88.21%)
      The 30-day readmission rate was nearly significantly lower in the initial-resumption cohort when compared to the pre-pandemic cohort (1.47% vs. 2.76%, STD = 0.09), but there was no significant difference in readmission rates between the pre-pandemic and later-resumption (30-day readmissions rate: 2.44%) cohort (STD = 0.02). During the pandemic, fewer patients were discharged to institutional post-acute care, as the rates were 19.90%, 9.39% (STD = 0.301), and 11.79% (STD = 0.224) for the pre-pandemic, initial resumption cohort, and later-resumption cohort respectively. Discharges to institutional post-acute care remained low during the later-resumption period, as there was no significant difference between the initial-resumption and later-resumption cohorts (STD = 0.078).
      Multivariable logistic regression analysis for prolonged LOS, discharge to institutional post-acute care, and 30-day readmissions is summarized in Table 3. Compared to pre-pandemic TJA cases, patients were less likely to have a LOS ≥ 2 days during the initial-resumption (OR: 0.47, 95% CI: 0.41–0.54, p < 0.0001) and later-resumption (OR: 0.55, 95% CI: 0.48–0.63, p < 0.0001) time periods. Patients were also less likely to be discharged to an institutional post-acute care facility in the initial-resumption (OR: 0.48, 95% CI: 0.40–0.59, p < 0.0001) and later-resumption (OR: 0.63, 95% CI: 0.53–0.75, p < 0.0001) cohorts compared to patients who underwent TJA prior to the COVID-19 pandemic. Patients who underwent TJA during the initial resumption period were significantly less likely to be readmitted within 30-days compared to pre-pandemic patients (OR: 0.62, 95% CI: 0.40–0.98, p = 0.0412), however there was no difference in 30-day readmission likelihood when comparing pre-pandemic and later-resumption patients (OR: 0.96, 95% CI: 0.65–1.41, p = 0.8317).
      Table 3Multivariable Logistic Regression Models Assessing Impact of TJA Time Period on Prolonged Length of Stay, Discharge to Institutional Post-Acute Care, and 30-Day Readmissions.
      Prolonged LOSDischarge to Institutional Post-Acute Care30-Day Readmissions
      OR (95% CI)p-valueOR (95% CI)p-valueOR (95% CI)p-value
      TIME PERIOD
      Pre-pandemic*
      initial-resumption0.47 (0.41–0.54)<0.00010.48 (0.40–0.59)<0.00010.62 (0.40–0.98)0.0412
      later-resumption0.55 (0.48–0.63)<0.00010.63 (0.53–0.75)<0.00010.96 (0.65–1.41)0.8317
      *indicates reference category.

      4. Discussion

      The COVID-19 pandemic, which has caused over 4.1 million deaths worldwide as of July 2021, resulted in significant delays in access to medical and surgical care, particularly in the year 2020 [
      • Wilson J.M.
      • Schwartz A.M.
      • Farley K.X.
      • Roberson J.R.
      • Bradbury T.L.
      • Guild G.N.
      Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19.
      ]. As New York City quickly became a pandemic epicenter in March and April 2020, elective surgical procedures were quickly halted and not resumed until June 8, 2020 [
      • Zachariah P.
      • Johnson C.L.
      • Halabi K.C.
      • Ahn D.
      • Sen A.I.
      • Fischer A.
      • et al.
      Epidemiology, Clinical Features, and Disease Severity in Patients With Coronavirus Disease 2019 (COVID-19) in a Children’s Hospital in New York City, New York.
      ,
      • Rizkalla J.M.
      • Gladnick B.P.
      • Bhimani A.A.
      • Wood D.S.
      • Kitziger K.J.
      • Peters Jr., P.C.
      Triaging Total Hip Arthroplasty During the COVID-19 Pandemic.
      ,
      • Poeran J.
      • Zhong H.
      • Wilson L.
      • Liu J.
      • Memtsoudis S.G.
      Cancellation of Elective Surgery and Intensive Care Unit Capacity in New York State: A Retrospective Cohort Analysis.
      ]. Among the most common orthopedic procedures, THAs and TKAs made up a significant proportion of the delayed surgeries. The goal of this study was to assess the effect of the pandemic on TJA care patterns through an evaluation of patient characteristics, surgical characteristics, and postoperative outcomes.
      There were significant differences in several key patient characteristics when comparing TJAs performed prior to the pandemic and post-resumption of elective surgery during the pandemic. During the pandemic period, especially during the initial resumption period, patients who underwent TJAs were younger, had healthier physical status scores, and had fewer risk factors for adverse outcomes than patients who underwent TJAs prior to the pandemic. Patients ≥ 65 years of age made up over 55% of the total pre-pandemic TJA cohort, while patients ≥ 65 years of age only made up around 50% of the total TJAs during the initial resumption period (June 8, 2020–September 8, 2020) and later-resumption period (September 9, 2020–December 8, 2020).
      The proportion of underweight patients was significantly smaller during the pandemic than prior to it, as the percent of TJAs performed on patients with BMI < 18 decreased from 4.12% pre-pandemic to 0.74% and 0.32% during the initial resumption and later-resumption periods respectively. Prior studies have identified an association between low BMI and increased LOS, increased mortality, as well as increased risk for adverse outcomes such as postoperative anemia and deep vein thrombosis in TJA [
      • Sayeed Z.
      • Anoushiravani A.A.
      • Chambers M.C.
      • Gilbert T.J.
      • Scaife S.L.
      • El-Othmani M.M.
      • et al.
      Comparing In-Hospital Total Joint Arthroplasty Outcomes and Resource Consumption Among Underweight and Morbidly Obese Patients.
      ,
      • Katakam A.
      • Melnic C.M.
      • Bragdon C.R.
      • Sauder N.
      • Collins A.K.
      • Bedair H.S.
      Low Body Mass Index Is a Predictor for Mortality and Increased Length of Stay Following Total Joint Arthroplasty.
      ]. Patients who underwent TJA during both pandemic periods also had lower ASA scores, as patients with ASA ≥ 3 accounted for 46% of cases pre-pandemic, 41% during the initial resumption period, and 39% during the later-resumption period. Prior studies have identified the association between higher ASA scores and increased complications, readmissions, and mortality [
      • Schaeffer J.F.
      • Scott D.J.
      • Godin J.A.
      • Attarian D.E.
      • Wellman S.S.
      • Mather R.C.
      The Association of ASA Class on Total Knee and Total Hip Arthroplasty Readmission Rates in an Academic Hospital.
      ,
      • Gronbeck C.
      • Cote M.P.
      • Lieberman J.R.
      • Halawi M.J.
      Risk stratification in primary total joint arthroplasty: the current state of knowledge.
      ]. In a study of 14,185 patients who underwent TJA, Gronbeck et al. determined that the ASA score was a better risk stratification tool for TJA patients than the CCI, and that higher ASA scores were risk factors for medical complications, surgical complications, 30-day readmission, and mortality [
      • Gronbeck C.
      • Cote M.P.
      • Lieberman J.R.
      • Halawi M.J.
      Risk stratification in primary total joint arthroplasty: the current state of knowledge.
      ].
      Differences in proportion of patients by race were also noticed across the three time periods. While non-white patients made up 58% of total TJA cases prior to the pandemic, nonwhite patients only accounted for 53.5% of cases during the 3-month period immediately following the resumption of elective surgery in New York City (STD = 0.099). In the subsequent 3 months (September 9–December 8, 2020), levels of nonwhite patients (59%) returned to pre-pandemic levels (STD comparing pre-pandemic and later-resumption cohorts: 0.006, STD comparing initial-resumption and later-resumption cohorts: 0.105). This data underscores decreased access to care for nonwhite patients in the period immediately following resumption of elective surgery in New York City, and unfortunately reflects healthcare disparities that minorities have faced throughout the COVID-19 pandemic [
      • Vahidy F.S.
      • Nicolas J.C.
      • Meeks J.R.
      • Khan O.
      • Pan A.
      • Jones S.L.
      • et al.
      Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population.
      ,
      • Renelus B.D.
      • Khoury N.C.
      • Chandrasekaran K.
      • Bekele E.
      • Briggs W.M.
      • Ivanov A.
      • et al.
      Racial Disparities in COVID-19 Hospitalization and In-hospital Mortality at the Height of the New York City Pandemic.
      ].
      Decreased length of stay for TJA patients was noted during the pandemic, as LOS > 2 days dropped from 83% prior to the pandemic to 67% in the initial resumption period and 70% in the later-resumption period. Decreased LOS was in fact independently associated with TJAs performed during the two pandemic periods, initial-resumption (OR: 0.47, 95% CI: 0.41–0.54, p < 0.0001) and later-resumption (OR: 0.55, 95% CI: 0.48–0.63, p < 0.0001). Despite decreases in hospital LOS for patients, we did not see an increase in 30-day readmissions during the two pandemic periods. In fact, patients were less likely to be readmitted during the initial resumption period (OR: 0.62, 95% CI: 0.40–0.98, p = 0.0412) and not more likely to be readmitted during the later-resumption period (OR: 0.96, 95% CI: 0.65–1.41, p = 0.8317) when compared to pre-pandemic TJAs. Similarly, in a study analyzing 172,760 patients who underwent TJA over a 15-year period, Kirkland et al. found that increased index length of stay was associated with increased risk of readmission [
      • Kirkland P.A.
      • Barfield W.R.
      • Demos H.A.
      • Pellegrini Jr., V.D.
      • Drew J.M.
      Optimal Length of Stay Following Total Joint Arthroplasty to Reduce Readmission Rates.
      ]. Altogether, decreased LOS is not associated with increased readmissions in TJA.
      Additionally, we found a highly significant decrease in discharge to institutional post-acute for patients who underwent TJA during either of the pandemic periods. Non-home discharge rates dropped from 19.90% of cases pre-pandemic to 9.39% (STD = 0.301) and 11.79% (STD = 0.224) for patients who underwent surgery during the pandemic between June 8–September 8, 2020 and September 9–December 8, 2020 respectively. Lower odds of discharge to institutional post-acute care during the initial-resumption (OR: 0.48, 95% CI: 0.40–0.59, p < 0.0001) and later-resumption (OR: 0.63, 95% CI: 0.53–0.75, p < 0.0001) time periods were also supported by multivariate analysis. Post-acute care facilities were especially at-risk environments for COVID-19 transmission and infection, and this explains the significant drop in discharge to these facilities post-TJA during the two pandemic time periods. As of November 2020, Skilled Nursing Facilities had accounted for around 40% of all COVID-related mortality in the United States [
      • SteelFisher G.K.
      • Epstein A.M.
      • Grabowski D.C.
      • Joynt Maddox K.E.
      • Orav E.J.
      • Barnett M.L.
      Persistent challenges of COVID-19 in skilled nursing facilities: The administrator perspective.
      ,
      • Angevine P.D.
      • Bridwell K.H.
      Sagittal Imbalance.
      ]. Despite decreased discharge to institutional post-acute care facilities, we noticed no increase in readmissions for patients who underwent TJA during the pandemic periods. Thirty-day readmission rates were in fact lower during the initial-resumption time period (OR: 0.62, 95% CI: 0.40–0.98, p = 0.0412) and not higher during the later-resumption time period (OR: 0.96, 95% CI: 0.65–1.41, p = 0.8317) compared to the pre-pandemic period. This was the case when controlling for factors that typically influence discharge destination such as comorbidity burden, physical status, BMI, and age. This data suggests that discharge to post-acute care facilities need not be as frequent as it was prior to the pandemic. Post-TJA discharge to post-acute care facilities have been associated with increased costs, frequency of adverse events, decreased patient satisfaction, and similar functional outcomes when compared to home discharge [
      • Tiwari V.
      • Park C.K.
      • Lee S.W.
      • Kim M.J.
      • Seong J.S.
      • Kim T.K.
      Does Discharge Destination Matter after Total Knee Arthroplasty? A Single-Institution Korean Experience.
      ,
      • Keswani A.
      • Tasi M.C.
      • Fields A.
      • Lovy A.J.
      • Moucha C.S.
      • Bozic K.J.
      Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends.
      ,
      • Keswani A.
      • Weiser M.C.
      • Shin J.
      • Lovy A.J.
      • Moucha C.S.
      Discharge Destination After Revision Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes and Placement Risk Factors.
      ,
      • Fang C.
      • Lim S.J.
      • Tybor D.J.
      • Martin J.
      • Pevear M.E.
      • Smith E.L.
      Factors Determining Home versus Rehabilitation Discharge Following Primary Total Joint Arthroplasty for Patients Who Live Alone.
      ].

      5. Conclusions

      Altogether, patients who underwent TJA during the pandemic were younger and had healthier physical status scores. Non-white patients were at a disadvantage when it came to access to TJA in the period immediately following resumption of elective surgery in NYC. Hospital LOS and discharge to institutional post-acute care were both lower throughout the pandemic. 30-day readmissions did not increase throughout the pandemic, and in fact readmissions were significantly lower in the 3-month period following resumption of elective surgery than in the pre-pandemic period, suggesting that discharge to post-acute care facilities need not return to the higher pre-pandemic level for TJA cases.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      References

        • O’Connor C.M.
        • Anoushiravani A.A.
        • DiCaprio M.R.
        • Healy W.L.
        • Iorio R.
        Economic Recovery After the COVID-19 Pandemic: Resuming Elective Orthopedic Surgery and Total Joint Arthroplasty.
        J Arthroplasty. 2020; 35: S32-S36https://doi.org/10.1016/j.arth.2020.04.038
        • Kalakoti P.
        • Gao Y.
        • Hendrickson N.R.
        • Pugely A.J.
        Preparing for Bundled Payments in Cervical Spine Surgery: Do We Understand the Influence of Patient, Hospital, and Procedural Factors on the Cost and Length of Stay?.
        Spine. 2019; 44 (https://journals.lww.com/spinejournal/Fulltext/2019/03010/Preparing_for_Bundled_Payments_in_Cervical_Spine.9.aspx.)
        • Zachariah P.
        • Johnson C.L.
        • Halabi K.C.
        • Ahn D.
        • Sen A.I.
        • Fischer A.
        • et al.
        Epidemiology, Clinical Features, and Disease Severity in Patients With Coronavirus Disease 2019 (COVID-19) in a Children’s Hospital in New York City, New York.
        JAMA Pediatr. 2020; 174: e202430https://doi.org/10.1001/jamapediatrics.2020.2430
        • Mikami T.
        • Miyashita H.
        • Yamada T.
        • Harrington M.
        • Steinberg D.
        • Dunn A.
        • et al.
        Risk Factors for Mortality in Patients with COVID-19 in New York City.
        J Gen Intern Med. 2021; 36: 17-26https://doi.org/10.1007/s11606-020-05983-z
        • Rizkalla J.M.
        • Gladnick B.P.
        • Bhimani A.A.
        • Wood D.S.
        • Kitziger K.J.
        • Peters Jr., P.C.
        Triaging Total Hip Arthroplasty During the COVID-19 Pandemic.
        Curr Rev Musculoskelet Med. 2020; 13: 416-424https://doi.org/10.1007/s12178-020-09642-y
        • Wilson J.M.
        • Schwartz A.M.
        • Farley K.X.
        • Roberson J.R.
        • Bradbury T.L.
        • Guild G.N.
        Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19.
        HSS J. 2020; 16: 85-91https://doi.org/10.1007/s11420-020-09806-z
        • Poeran J.
        • Zhong H.
        • Wilson L.
        • Liu J.
        • Memtsoudis S.G.
        Cancellation of Elective Surgery and Intensive Care Unit Capacity in New York State: A Retrospective Cohort Analysis.
        Anesth Analg. 2020; 131: 1337-1341https://doi.org/10.1213/ANE.0000000000005083
        • Koenig L.
        • Zhang Q.
        • Austin M.S.
        • Demiralp B.
        • Fehring T.K.
        • Feng C.
        • et al.
        Estimating the Societal Benefits of THA After Accounting for Work Status and Productivity: A Markov Model Approach.
        Clin Orthop Relat Res. 2016; 474: 2645-2654https://doi.org/10.1007/s11999-016-5084-9
        • Bedair H.
        • Cha T.D.
        • Hansen V.J.
        Economic benefit to society at large of total knee arthroplasty in younger patients: a Markov analysis.
        J Bone Joint Surg Am. 2014; 96: 119-126https://doi.org/10.2106/jbjs.L.01736
        • Farcy J.P.
        • Schwab F.J.
        Management of flatback and related kyphotic decompensation syndromes.
        Spine (Phila Pa 1976). 1997; 22: 2452-2457https://doi.org/10.1097/00007632-199710150-00025
        • Jella T.K.
        • Samuel L.T.
        • Acuña A.J.
        • Emara A.K.
        • Kamath A.F.
        Rapid Decline in Online Search Queries for Hip and Knee Arthroplasties Concurrent With the COVID-19 Pandemic.
        J Arthroplasty. 2020; 35: 2813-2819https://doi.org/10.1016/j.arth.2020.05.051
        • Quan H.
        • Sundararajan V.
        • Halfon P.
        • Fong A.
        • Burnand B.
        • Luthi J.-C.
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139https://doi.org/10.1097/01.mlr.0000182534.19832.83
        • Austin P.C.
        An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies.
        Multivariate Behav Res. 2011; 46: 399-424https://doi.org/10.1080/00273171.2011.568786
        • Sayeed Z.
        • Anoushiravani A.A.
        • Chambers M.C.
        • Gilbert T.J.
        • Scaife S.L.
        • El-Othmani M.M.
        • et al.
        Comparing In-Hospital Total Joint Arthroplasty Outcomes and Resource Consumption Among Underweight and Morbidly Obese Patients.
        J Arthroplasty. 2016; 31: 2085-2090https://doi.org/10.1016/j.arth.2016.03.015
        • Katakam A.
        • Melnic C.M.
        • Bragdon C.R.
        • Sauder N.
        • Collins A.K.
        • Bedair H.S.
        Low Body Mass Index Is a Predictor for Mortality and Increased Length of Stay Following Total Joint Arthroplasty.
        J Arthroplasty. 2021; 36: 72-77https://doi.org/10.1016/j.arth.2020.07.055
        • Schaeffer J.F.
        • Scott D.J.
        • Godin J.A.
        • Attarian D.E.
        • Wellman S.S.
        • Mather R.C.
        The Association of ASA Class on Total Knee and Total Hip Arthroplasty Readmission Rates in an Academic Hospital.
        J Arthroplasty. 2015; 30: 723-727https://doi.org/10.1016/j.arth.2014.12.014
        • Gronbeck C.
        • Cote M.P.
        • Lieberman J.R.
        • Halawi M.J.
        Risk stratification in primary total joint arthroplasty: the current state of knowledge.
        Arthroplasty Today. 2019; 5: 126-131https://doi.org/10.1016/j.artd.2018.10.002
        • Vahidy F.S.
        • Nicolas J.C.
        • Meeks J.R.
        • Khan O.
        • Pan A.
        • Jones S.L.
        • et al.
        Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population.
        BMJ Open. 2020; 10: e039849https://doi.org/10.1136/bmjopen-2020-039849
        • Renelus B.D.
        • Khoury N.C.
        • Chandrasekaran K.
        • Bekele E.
        • Briggs W.M.
        • Ivanov A.
        • et al.
        Racial Disparities in COVID-19 Hospitalization and In-hospital Mortality at the Height of the New York City Pandemic.
        J Racial Ethnic Health Disparities. 2021; 8: 1161-1167https://doi.org/10.1007/s40615-020-00872-x
        • Kirkland P.A.
        • Barfield W.R.
        • Demos H.A.
        • Pellegrini Jr., V.D.
        • Drew J.M.
        Optimal Length of Stay Following Total Joint Arthroplasty to Reduce Readmission Rates.
        J Arthroplasty. 2020; 35 (303–8.e1)https://doi.org/10.1016/j.arth.2019.08.059
        • SteelFisher G.K.
        • Epstein A.M.
        • Grabowski D.C.
        • Joynt Maddox K.E.
        • Orav E.J.
        • Barnett M.L.
        Persistent challenges of COVID-19 in skilled nursing facilities: The administrator perspective.
        J Am Geriatr Soc. 2021; 69 (https://doi.org/https://doi.org/10.1111/jgs.17062): 875-878
        • Angevine P.D.
        • Bridwell K.H.
        Sagittal Imbalance.
        Neurosurg Clin N Am. 2006; 17: 353-363
        • Tiwari V.
        • Park C.K.
        • Lee S.W.
        • Kim M.J.
        • Seong J.S.
        • Kim T.K.
        Does Discharge Destination Matter after Total Knee Arthroplasty? A Single-Institution Korean Experience.
        Knee Surg Relat Res. 2018; 30: 215-226https://doi.org/10.5792/ksrr.17.060
        • Keswani A.
        • Tasi M.C.
        • Fields A.
        • Lovy A.J.
        • Moucha C.S.
        • Bozic K.J.
        Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends.
        J Arthroplasty. 2016; 31: 1155-1162https://doi.org/10.1016/j.arth.2015.11.044
        • Keswani A.
        • Weiser M.C.
        • Shin J.
        • Lovy A.J.
        • Moucha C.S.
        Discharge Destination After Revision Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes and Placement Risk Factors.
        J Arthroplasty. 2016; 31 (1866–72.e1)https://doi.org/10.1016/j.arth.2016.02.053
        • Fang C.
        • Lim S.J.
        • Tybor D.J.
        • Martin J.
        • Pevear M.E.
        • Smith E.L.
        Factors Determining Home versus Rehabilitation Discharge Following Primary Total Joint Arthroplasty for Patients Who Live Alone.
        Geriatrics. 2020; 5 (https://www.mdpi.com/2308-3417/5/1/7): 7