Joseph Bosco, MD, is president of the American Academy of Orthopaedic Surgeons and professor and vice chair for clinical affairs of the NYU Langone department of orthopedic surgery in New York City.
Like many orthopedic physicians, Dr. Bosco's practice has seen a dramatic change since the onset of the COVID-19 pandemic.
Typically he devotes 35 hours a week to his clinical practice in the care of patients, but has seen that time cut in half over the past several weeks.
Operating at the epicenter of the pandemic in New York City, Dr. Bosco has pivoted to preparing the hospital's ORs and developing a roadmap to address the eventual return to essential orthopedic surgery.
Dr. Bosco spoke to Becker's Orthopedic Review about how to increase orthopedic surgery volumes and how a second COVID-19 wave could affect the field.
Question: What does AAOS deem an "elective" or essential orthopedic surgery during this time?
Dr. Joseph Bosco: AAOS put out a recommendation for a return to essential surgery. We don't like to use elective and nonelective because there is a continuum between the two, and frankly, we do not believe that any orthopedic surgery is truly elective. Elective surgery is traditionally defined as a surgery in which a delay causes no patient harm. There are certain surgeries that everyone agrees are emergent. For instance if a patient is exsanguinating minutes can matter. If you postpone some orthopedic surgeries, such as compartment releases for acute compartment syndromes, more than a couple of hours they can cause harm to the patient. Other surgeries — like certain kinds of fractures — can be postponed for two to three weeks before the patients are harmed. A joint replacement, a carpal tunnel release or certain sports medicine procedures may be postponed a month or two without harming the patient. No one is better to judge what surgery is important or a priority than the surgeon taking care of the patient.
At some point, if any orthopedic procedure is delayed long enough, the patient will be harmed. We're getting to that point now with most centers closed down for about eight weeks. Some patients have been waiting that time to have surgery. If you add on another month or two of waiting prior to the COVID-19 pandemic and, there's going to be a lot of patients waiting three to four months, which is a long time to be living in pain.
Q: What factors should orthopedic practices consider when making the decision to return to essential surgery?
JB: The decisions to return to essential orthopedic surgery should be made on a regional basis, and made in conjunction with public authorities and healthcare professionals. You don't want authorities making these decisions without a physician and you don't want physicians making the decisions without the authorities. It's got to be a combination. These decisions need to be based on the availability of resources, which is everything from personnel to ventilators, to ICU beds and to personal protective equipment. This varies greatly from region to region.
The second part should be based on how many COVID-19 cases you have in your area and whether you're in a hot zone like New York or you're in a place that has a very low level of COVID-19 patients. Even if your practice is in a region that has a low level of COVID -19 burden, but that level is increasing, you must be cautious about resuming surgery. Basically two factors influence the decision to resume surgery:
1) The overall amount of COVID-19.
2) The part of the disease curve you are on.
Basically, if the amount of COVID-19 cases are decreasing, the curve is flattening out, you have ample resources, as well as the ability to test and track, we think it's OK to safely — in a measured, incremental way — resume essential surgery.
Q: How should practices approach increasing patient volumes?
JB: Again, it should be done in an incrementally, measured way. First you start cautiously with relatively healthy patients who will not require a substantial amount of resources. Then re-measure, make sure your resources are available and that the COVID-19 burden hasn't gone up. If the restart has not triggered a resurgence in COVID-19, then you can increase the amounts and acuity of surgery. Again, this is highly regionalized. For example, Oklahoma has been open for elective surgery in a measured fashion since April 27, because its COVID-19 burden has been incredibly low.
Q: What is the biggest challenge facing the orthopedic field at the moment?
JB: I think the biggest challenge is that we know so little about the SARS CoV-2 virus, so it is difficult to predict the future. The good news is that we are learning more and more about it on a daily basis. Because of this, patients are reticent to come to hospitals and see physicians because they're afraid of contracting COVID-19. Even if the hospital is taking every precaution, patients are still reluctant to come in where there may be COVID-19 patients, and you really can't blame them for that.
The shelter in place and social distancing regulations has resulted in a large decrease in the activity level of our population. For those of us in sports medicine and trauma, a lot of what we do is taking care of people injured during activities. There's no high school, college or professional sports and no adult recreation leagues, so there's not too many people in need of our services at the moment.
Q: What sort of patient volume are you expecting at NYU Langone as the hospital begins to address the surgical backlog?
JB: At NYU Langone, we conducted a study of about 200 of our joint replacement patients that were scheduled for surgery, but whose surgery had to be canceled due to COVID-19. We contacted each patient and found that about a third of them wanted their surgery as soon as possible, a third wanted surgery in three to six months and a third were undecided. In New York City especially, I think a lot of people are still undecided about when they're going to have surgery. Patients are justifiably skittish, which we understand and support their decisions.
Because the COVID-19 burden has decreased and our resources are adequate at NYU, we're starting to address the backlog of our surgical patients. Our department performs about 25,000 surgeries a year. In the past six weeks we had 1,200 patients that were scheduled for surgery that we had to cancel. So, we have those 1,200 patients that need to be addressed.
Q: If a second COVID-19 wave comes in the fall, how will that affect the orthopedic field?
JB: Our practices have been deeply affected by the pandemic. Most of our physicians have been able to keep their practices viable. The Payment Protection Program, Small Business Association loans, Provider Relief Fund and the Medicare Advanced Payment Program have all helped physicians maintain their office staff and practice. When the average physician employs six or seven people, it's difficult to keep their staff intact during this time. However, it is vital that we do so in order to provide the high value care our patients are accustomed to when the pandemic ends.
Many of us have been called into service at hospitals to take care of COVID-19 patients. It'll be a concern for our patients if the second wave does come around. I'm concerned for our physicians, but I'm more concerned about our patients and our country in general if we have a second wave that's just as bad as this one. However, I am confident that our profession and country can survive anything that this virus throws at us.