4. The ethical challenge of COVID-19 and primary hip and knee replacement
Nanne Kort, MD, PhD
Chief Medical Officer at CortoClinics | Taking the next step in Hip and Knee care
Resuming elective primary hip and knee replacement too soon or too late should be avoided, and achieving graduated reinstatement will be an ongoing challenging in any event.
As this crisis continues, we are thinking about all our patients who are now having to wait for their hip and knee replacements; we want to be able to help everyone immediately. However, the reality is that we all need to take measures to slow the spread of the COVID-19 virus and protect our patients. The COVID-19 pandemic has produced a severe downturn in primary hip and knee replacements worldwide (1), for which we have no script (2,3). In addition, the pandemic is having a considerable negative economic impact on health care in Europe, raising ethical issues about the importance of health care safety and health care survival.
The favourable influence of hip and knee replacement on mobility, social life, preventing cardiovascular disease, promoting general health, increasing patient satisfaction, decreasing pain and improving joint function, especially in the elderly, is beyond dispute (4). Postponing hip and knee surgery may increase functional limitations and eventually result in the loss of independence for many patients. On the other hand, performing such surgeries under the current conditions could increase the risks related to surgery and postoperative recovery, particularly in older patients, who are more prone to cardiovascular disease, coagulopathies, diabetes mellitus, pulmonary disease or other comorbidities highly associated with death from COVID-19. Moreover, rehabilitation time could be really problematic due to the lack of facilities including at-home services, while admissions for rehabilitation are restricted to the minimum even for the older population, when not suspended entirely. Therefore, careful ethical evaluation will be required at a certain centre and for a certain patient before performing hip and knee operations to discuss the pros and cons of surgery versus delaying treatment. Shared decision making with the patients and their relatives in terms of considering both the general risks they may face and the additional ones brought on by the pandemic will be imperative. Finally, we must ensure that any elective care surgery does not conflict with appropriately defined urgent surgery needed to address other problems and help other patients.
Over a quarter million people have died worldwide from the effects of the coronavirus that spread from China, although the actual number is presumably higher. The death toll has more than doubled in two weeks. More than 3.6 million people are known to be infected, according to reports from Johns Hopkins University (5). France is extending its emergency measures for fighting the coronavirus by two months, to 24 July: the government reached an agreement in Paris on a bill to that effect on Saturday, 2 May, according to the Minister of Health, Olivier Véran. Meanwhile, people in Austria were allowed to start moving about freely as of last Friday, 1 May. They had been confined to their homes since mid-March but now no longer need any particular reason to go out. The death toll from the coronavirus in Italy increased by 474 on 1 May, compared to 269 the day before, as reported by the country’s civil protection agency. It was the highest death toll since 21 April. For the second day in a row, fewer than 100 people died in Germany from the effects of COVID-19. According to a report 1 May from the Robert Koch-Institute, 74 deaths had been registered in the past 24 hours; the day before that, the number had been 94, and on Thursday, 30 April, it was 173. These numbers show that while we are on a better path, we are not yet out of the woods, so prudence is required.
We are seeing a beautiful downward trend in infections on the graph of new COVID-19 cases in Europe (Table 1), and WHO/Europe has published critical considerations for the gradual easing of the lockdown restrictions introduced by many countries in response to the virus’s spread across the European Region. We are now entering a new phase in most European countries, in which we can consider restarting elective hip and knee replacement in a "post" pandemic period. It is still crucial, however, to bear in mind that hip and knee replacement is an elective operation and not urgent or acute, when direct intervention is necessary, which presents a very new scenario, and also that the safety of our patients and staff remains of paramount importance.
The COVID-19 pandemic constitutes an unprecedented challenge with very severe socio-economic consequences (6). The proposal for a Coronavirus Response Investment Initiative was approved by the European Parliament and the Council and is in force as of 1 April. This will allow the use of EUR 37 billion under the cohesion policy to address the consequences of the COVID-19 crisis. In addition, the scope of the Solidarity Fund was broadened to include major public health crises. Starting from 1 April, this allows the hardest hit Member States to get access to the financial support of up to EUR 800 million that has been made available in 2020.
The global joint replacement devices market is projected to exceed $20.2 billion by 2025, growing at a CAGR of 4.6% over the forecast period, driven by technological advancement and higher preference for and adoption of minimally invasive surgeries worldwide. Indeed, the demand for joint replacement devices is expected to double within 10 years, driven by robotically assisted operations, ageing populations, improvements in surgical and pain management techniques and moderate incremental innovations (7).
Since 2000, the number of hip and knee replacements has increased rapidly in most OECD countries. On average, hip replacement rates increased by 30% between 2007 and 2017 and knee replacement rates by 40%. This aligns with the rising incidence and prevalence of osteoarthritis caused by ageing populations and growing obesity rates in OECD countries (8). In 2017, Germany, Austria, Switzerland, Finland, Luxembourg and Belgium were among the countries with the highest numbers of hip and knee replacements. In the USA, elective procedures account for 48% of hospital costs and potentially an even more significant percentage of revenues. Five musculoskeletal surgeries (hip arthroplasty, knee arthroplasty, laminectomy, spinal fusion and treatment of lower extremity fracture or dislocation) account for 17% of all operating room procedures in US hospitals (9).
Without elective hip and knee replacement procedures, our patients are at risk of increasing pain and less mobility, and our health care institutions are at risk of insolvency. Patient risks derived from the lack of elective hip and knee replacements include less independence due to joint pain or even joint destruction, which may also impact their ability to survive in isolation or under difficult social circumstances. Moreover, there is an increased risk of drug abuse by suffering patients. There should be a balance between the risks and safety for our patients/staff and the economic pressure to restart the replacement business.
Unfortunately, COVID-19 has had a tremendous negative impact on economic growth in 2020 (Table 2). Hospitals are on the front lines and vulnerable to this economic disruption as they face challenges and hits to their revenue from the cancellation of elective surgeries. They have had to stop most non-COVID-related activity to respond to the urgent demands of infected patients. As a result, health care providers are experiencing a significant reduction in revenue, while at the same time seeing increased staff and supply costs. Moreover, hospitals are unlikely to see ongoing contributions from non-operating income because their investment portfolios have been hurt, as well. Even before the coronavirus outbreak, many health care providers were struggling financially. The orthopaedic industry has also been witnessing a loss of business. Many orthopaedic companies have proactively planned for their worst-case scenarios and reset their expense line to protect employees, customers and investors. There is a boom expected in hip and knee replacements in the second half of 2020 once these procedures can be restarted, and revenue will once again be generated from such surgeries.
In conclusion, there has been a downward trend in COVID-19 cases/deaths, as mentioned above. But there is an upward trend for the economic impact of COVID-19 on the health care institutions, orthopaedic industry and health care providers. These lines will eventually intersect, depending on what country you live in (Table 3). Restarting hip and knee replacement at this moment of intersection is the challenge (Table 3 B). If we start up hip and knee replacements earlier (Table 3 A), we may endanger patients and staff. If we start later (Table 3 C), we may jeopardise the health care institutions in an already fragile health economy.
An ethical discussion awaits us: at what stage do we allow the safety of patients and staff to prevail, and at what stage do we allow the economic side of this discussion to prevail (10)? Above all, what is the safest, most effective way to treat our patients suffering from joint disease in a timely manner? The circumstances are different in every country, with a disparate impact of COVID-19 on the population and health care providers. We need to find the right balance between medical safety and economic safety. In any event, “the decision to treat must not be based on financial reasons. In both privately and publicly funded systems, the decisions about the form of treatment that is offered should be based on need and not on finance” (11).
One thing is sure, with the downward trend in COVID-19 cases and deaths, there has been more and more focus on its economic impact, with tremendous pressure to restart primary hip and knee replacements in Europe. At the same time, pressure from patients is growing to be operated on soon as they begin to feel safer with the pandemic’s evolution. “In times of financial restraint, we know the problems caused when cost savings are achieved at the expense of patient care (12).”
We should be ready to decide on challenging ethical issues related to primary hip and knee replacement with the support of the existing evidence-based practices and expert opinion data/recommendations. Each item should reflect the status in Europe as a whole, but you should also keep in mind what is going on locally in your country, or even in different areas of the largest countries.
What are the challenging issues (in random order) we need to bear in mind in terms of resuming elective hip and knee replacement?
? Who should receive orthopaedic surgical care and how long can hip and knee replacement be delayed as related to the patient’s osteoarthritis complaints and the available resources?
? There are priority lists for restarting elective surgery. Primary hip and knee replacement does not have a high ranking. How much would quality of life need to be improved to counterbalance the risks of surgery? Which cases among elective hip and knee replacement should be prioritized (the worst joint or the worst-off patient)? Is elective revision surgery for hip and knee replacements a priority?
? What are the complication risks for patients receiving a hip or knee replacement? Do they increase with the COVID-19 pandemic, and how can we minimize the risks?
? What is the role of shared decision making, including legal aspects, and specific informed consent with respect to the orthopaedic surgeon and the patient?
? How significant is the pressure to restart primary hip and knee replacements to generate revenue from the surgeries?
Resuming elective primary hip and knee replacement too soon or too late should be avoided, and achieving graduated reinstatement will be an ongoing challenging in any event. It is important for everyone, both surgeons and patients, to think about the timing from the perspective of both medical safety and economic safety. We need to be honest about the scale of the challenges ahead and realize that the health challenges and economic consequences are potentially devastating.
Please feel free to participate by contacting: [email protected].
On behalf of the COVID-19 and primary hip and knee replacement team empowered by the European Hip Society and European Knee Associates
References:
1
D’Apolito R, Faraldi M, Ottaiano I, Zagra L. Disruption of Arthroplasty practice in an orthopaedic center in northern Italy during COVID-19 pandemic. J. Arthoplasty 2020 doi: https://doi.org/10.1016/j.arth.2020.04.057
2
3
Thaler M , Khosravi I, Hirschmann MT, Kort NP, Zagra L, Epinette JA, Liebensteiner MC. Disruption of Joint Arthroplasty Services in Europe during the COVID -19 Pandemic: an Online Survey within the European Hip Society (EHS) and the European Knee Associates (EKA) Knee Surg Sports Traumatol Arthrosc (2020) DOI: 10.1007/s00167-020-06033-1
4
5
6
7
https://www.ihealthcareanalyst.com/global-joint-replacement-devices-market/
8
OECD (2019), "Hip and knee replacement", in Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/2fc83b9a-en?
9
doi:10.2106/JBJS.20.00557. The Orthopaedic Forum. Economic Impacts of the COVID 19. Crisis. An Orthopaedic Perspective. Afshin A
10
J Bone Joint Surg Am. 2020;00:e1(1-4) d https://dx.doi.org/10.2106/JBJS.20.00524
11
Benson M, Boehler N, Szendroi M, Zagra L, Puget J. Ethical orthopaedics for EFORT, 2014. European Orthopaedics and Traumatology, 2014, Vol 5, Issue 1:1-8
12
Benson M, Boehler N, Szendroi M, Zagra L, Puget J. - Ethical standards for orthopaedic surgeons. - Bone Joint J. 2014 Aug;96-B(8):1130-2. doi: 10.1302/0301-620X.96B8.34206