The impact of COVID-19 on the orthopaedic patient in Slovenia: Hip and knee replacement surgery, 90-Day mortality, outpatient visits and waiting times

Coronavirus epidemics started in March 2020 and had a huge effect on elective surgery during the first wave, hip and knee arthroplasty included (1). Slovenia was one of the countries least affected in the first wave and most affected in the second wave of the epidemics (2). The health system had to prepare for high numbers of hospitalized COVID-19 patients. One of the measures was a reorganization of orthopaedic wards into COVID-19 treatment units in most general and both University Hospitals. At the same time, the public hospital specialized exclusively in orthopaedics remained open for most of the urgent revisions and other urgent orthopaedic cases as a referral hospital. A drop in elective surgeries, which we followed in The National Arthroplasty Registry of Slovenia (RES), i.e. hip and knee replacements, was inevitable.

Slovenia is a central European country with approximately two million inhabitants. The health system provides near-universal coverage paid by The Health Insurance Institute of Slovenia; co-payments are covered by private health insurance (3). They apply to most health services but not for infectious diseases, cancer, diabetes, congenital anomalies and neuromuscular diseases. In 2017, health expenditure accounted for 8.2% of GDP (4).

The first confirmed COVID-19 infection was reported on 4 March 2020 followed by the first lockdown on 12 March 2020. The country was successful in the control of the first wave in less than two months. The approach taken enabled the country to be the first in the EU to declare the end of the epidemic on 31 May 2020 (5). But after the summer holiday season the numbers started to increase very rapidly, so the declaration of the second wave and lockdown on 19 October 2020 was inevitable (2).

After the first wave, orthopaedic programmes were re-established as soon as the legal causes were eliminated (elective programmes were banned by a government decree) and the organizational issues of individual hospitals were resolved. In both lockdowns, the Minister of Health implemented strict control measures, all schools and educational institutions were closed, all public transport services stopped and all non-essential services shut. All non-essential outpatient visits and surgery appointments were put on hold with the exception of oncological services. This resulted in the cancellation of most elective surgeries. In the first lockdown, the recommendation was based on concerns about the quantity of personal protective equipment and blood components available at the time (6).

In May 2020 a study by the European Hip Society and European Knee Associates from 40 different countries stated that nearly all primary total joint arthroplasties were cancelled (92.6%), as well as aseptic revisions (94.7%). Urgent procedures (periprosthetic fractures, hip arthroplasty for femoral neck fractures and septic revisions for acute infection) were still being performed (7).

During the second lockdown, all general and university hospitals in Slovenia recruited all resources for COVID-19 patients’ treatment. The two University Medical Centres and general hospitals had to reorganize because of the massive input of COVID-19 patients. Orthopaedic departments were converted into COVID-19 departments and a part of the medical staff was transferred from surgery to COVID-19 departments (8).

Nevertheless, between the spring wave (March-May 2020) and the autumn wave of epidemics (October-December 2020), the registry recorded an increased number of elective arthroplasty surgeries.

The study aimed to analyse what the impact was of the COVID-19 pandemic on the healthcare of the orthopaedic patient, i.e. access to primary and revision hip and knee replacement surgery, change in 90-day mortality, waiting times and outpatient clinic visits in Slovenia.

A retrospective study analysing data routinely collected from the RES registry, which had 92% and nearly 100% completeness in 2019 for hip and knee replacements, respectively, has been made (9, 10). The calculation of completeness was made regarding the comparison of the forms gathered in the registry and the data of procedures paid by The Health Insurance Institute of Slovenia (11). The publicly available data on waiting times and outpatient clinic visits, comparing the years 2019 and 2020, stratified by month, has been studied.

The first wave of COVID-19 had a large impact on elective hip and knee primary replacements in Slovenia (84% and 92% decrease in April 2020, respectively), in the summer period the numbers mostly recovered up until the second wave when we noticed an 86% and 90% decline in November 2020, respectively. Very similar results were observed in Milan, Italy, where elective surgery in the first wave declined rapidly, going close to zero, outpatient admissions were restricted to cases that cannot be postponed, while emergencies increased due to the role played by the hospital as a referral orthopaedic centre during the pandemic (1). The history of pandemics suggests that there is no predictable temporal pattern for major pandemics, so the next waves of epidemics seemed inevitable (12). In the post-acute phase, a normal surgical programme can be resumed step-by-step, taking into account clear hygiene regulations, the occupancy of the ward and the operating room adjusted accordingly (13, 14). However, a quick return to the normal volume of surgeries can be obstructed by the fact that many patients refuse to undergo rescheduled surgery (15). We managed to increase the number of surgeries in the summer months, between two lockdowns, substantially. Accepting rescheduled surgery was not a problem in our population of patients. The specialized orthopaedic hospital as a referral hospital took the main role in regaining the numbers between the two waves.

Despite the temporary increase, the number of HR and KR in 2020 was 19% lower than in 2019. Nevertheless, the difference was not as prominent as we expected. Within these numbers, we did not find the drop to be statistically significant. The number of surgeries did not decrease significantly, however it was lower than the year before COVID-19. But, if we take into account a steady yearly increase in the number of surgeries by approximately 5% per year before the pandemic (16), then the decrease in surgeries is even more obvious.

The COVID-19 epidemics and their consequences were associated with higher all-cause mortality compared to previous years. There were more than 530000 additional deaths from January to December 2020, against the average number of deaths during the same period between 2016 and 2019 in the EU and in Iceland, Norway, Liechtenstein and Switzerland (17). The data from Italy showed increased 7-week mortality after surgery, which was 1.2% in 2020 compared to 0% in 2019 (18). According to the Population Registration Division in Slovenia, there were 3648 (17%) additional deaths in 2020 compared with the average between 2015 and 2019 (2). The highest increase in mortality was in November 2020, at 89.5% compared to 2019. The age group over 72 represents 72% and the age group 62 -71 years an additional 16% of all excess deaths (2). Since the mean age of orthopaedic patients at surgery is 68 years for primary THR and 83 years for primary Partial HR, we expected increased 90-day mortality after the hip and knee arthroplasty (9, 10). But our data did not support that. The answer is perhaps in the selection of patients for elective surgery. They are all screened for other illnesses (in the COVID-19 era they are tested also for this disease). The patients who underwent hip or knee replacement have also better relative survival compared to the Slovenian population (19). Other outcome indicators such as Patient Related Outcome Measures (PROMs) should be analysed to see the change in the quality of life, but we did not have access to routinely gathered data.

Accessibility to healthcare can be limited for several reasons, including cost, distance to the closest health facility and waiting times, and this may result in poorer health for people forgoing care (20). Nevertheless, hospital-related factors are more important than patient characteristics as explanations of variations in waiting times for orthopaedic surgery (21). The effect of the COVID-19 pandemic on waiting times for KR and HR in Slovenia showed 15% days per month higher waiting time on average for hip surgery and 12% for knee surgery in 2020 compared to 2019, which was less than we expected. In an OECD report, median waiting times for HR in 2019 ranged from 35 in Denmark to 250 days in Estonia. Slovenia with 393 days was at the tail end. The long waiting times are partly explained by the limited volume of specialist consultations reimbursed by public health insurance. According to the OECD report of 2018, Slovenia has the feature of no large differences in unmet needs for medical examination between high and low-income populations (20). The pattern is generally the same for knee replacement, where Slovenian patients have to wait 496 days for KR (20). In the UK, up until November 2020 the waiting list remained approximately double the size of the pre- COVID-19 waiting list (22). This was not the case in Slovenia, where the increase was 15% for HR and 12% for KR. However, with already long waiting times, even a relatively small increase can have a pronounced impact on patients’ health.

Analysis of the impact on outpatient visits of Medicare data showed overall outpatient visits decreased by 30.0% in the first half of 2020 (23). Cardiovascular visits conducted in the first 15 weeks of the COVID-19 pandemic decreased by 33.1% compared with the same period in 2019 (24). Interestingly, in our study outpatient orthopaedic visits dropped by only 14% in 2020 compared to 2019. The cause was in the disruption of services on the primary level as well as on the secondary level. This drop could be partially replaced by telemedicine solutions such as the telemonitoring, provision of healthcare services by remotely connecting patients with healthcare professionals and remote cooperation for the patient’s treatment between healthcare professionals who are physically at different locations (25). The experts in epidemiology, data science and statistics should make an epidemiological model that simulates different scenarios of the dynamics of the disease (26).

There are limitations to our study. When comparing the number of THR and KR in Slovenia one year before the pandemic (2019) and in the first year of the pandemic (2020), only the difference between outpatient clinics was statistically significant. The reason that other differences did not show a significant result could be because the reorganisation of planned surgeries during the summer of 2020 resulted in large month-to-month variations, and also that just two years were taken into consideration. Since the collection of data for The National Arthroplasty Registry started in 2019, there were no prior data available.

Based on the results, we can conclude that there was an inevitable loss of elective surgery and outpatient clinic visits in 2020, with an impact on orthopaedic patients’ needs. During the lockdowns, urgent surgeries were performed in a few hospitals with strictly divided departments and in a specialized orthopaedic hospital, which remained open for orthopaedic emergencies only and was all the time predominantly a COVID-19 “free” institution. A positive impact of the public system was that it enabled the circulation of patients between hospitals. So the majority of urgent revisions (KR and HR) during the first lockdown were made in the specialized orthopaedic hospital that served as a referral hospital. The same hospital was the first to resume a normal pre-pandemic volume of surgeries, followed by orthopaedic departments in general and university hospitals. This reorganization of the orthopaedic service in Slovenia and increasing volume of surgeries in COVID-19 “free” months have been an example of good practice to maintain the number of KR and HR at a fairly high level in 2020, so it should be taken as a recommendation for dealing with epidemic work conditions in orthopaedics.

In Slovenia, the cap on the number of surgeries per hospital can limit the yearly number of total HR and KR surgeries in public institutions (3). For the reduction of waiting times, it requires a range of policy initiatives, including higher spending, waiting-times target schemes, and other incentive mechanisms (27). Nevertheless, further investigations of lower health expenditure due to the outage of orthopaedic treatments are needed.

We thank Assist. Prof. Eva Podovšovnik, PhD for providing statistical help, and David Breznikar from NIJZ for providing data on waiting times.