An analysis of the effect of the COVID-19-induced joint replacement deficit in England, Wales, and Northern Ireland suggests recovery will be protracted

Listen to Andrew Duckworth and Jonathan French discuss the paper 'An analysis of the effect of the COVID-19-induced joint replacement deficit in England, Wales, and Northern Ireland suggests recovery will be protracted' published in the August 2024 issue of The Bone & Joint Journal.

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Transcript

[00:00:00] Welcome everyone to our BJJ podcast for the month of August. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As always, we'd like to thank you all for your continued comments and support, as well as a big gratitude to our many authors and colleagues who take part in the series, highlighting some of just the great, some of the great work published by our authors each month.

So today for our monthly podcast, I have the pleasure of being joined by the lead author on a paper published in the August edition of the BJJ entitled 'An analysis of the effect of the COVID-19-induced joint replacement deficit in England, Wales, and Northern Ireland suggests recovery will be protracted: an analysis of the National Joint Registry'.

So I'm very pleased to be joined by Mr Jonathan French, who is a clinical research fellow at the University of Bristol. Thanks very much for joining us, Jon. It's really good to have you with us. Thank you very much for having me. So Jon, the primary aim of this study was to quantify the backlog, analyze national trends, and predict the time to recovery of joint replacement in light of the COVID-19 pandemic and how it disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. So Jon, maybe as a background to the study for our listeners, can you give us some insights into the state of these services [00:01:00] prior to the pandemic?

Yeah, sure. So I confess I did a bit of a Google as to what was happening in 2019 before this podcast, and Theresa May was PM, was succeeded by Boris Johnson, and Trump was PM in the, well, President of the US.

Yeah. So In terms of the NHS there were four million patients on the waiting list back then, and that had increased from two million back in 2010. And even in 2019, no specialties were meeting the waiting list target of 92%, seen within 18 weeks. And if you look specifically at hip and knee replacements in England, more than a quarter of patients were waiting more than 18 weeks for surgery, even back then.

Yeah, and that's, and that's interesting Jon isn't it, because I think that puts into context the paper and the data you're about to discuss with us, because even back then it wasn't quite right either, was it? And there was still a big problem. Yeah. And so what about, what about data we have already on how maybe provision was affected and [00:02:00] changed? I mean, even maybe even recovered since the pandemic. Is there anything out there already?

Yeah, so our unit published an earlier study along similar lines to this one, where they looked at the numbers just in 2019 and 2020, and that was joint replacements done in England, Wales, Northern Ireland, very similar methods.

And what they found was that in 2020 we lost around half a year's worth of procedures. And the impact was seen more in Scotland sorry, not Scotland Wales and Northern Ireland about 20% more. 

Yeah, that's very interesting. And that moves us very nicely on to your sort of work that you've done here. So this was a prospective observational registry-based study. It involved analysis of the NJR for all hip, knee, shoulder, elbow and ankle replacements in England, Wales and Northern Ireland between January 2019 and December 2022 inclusive, which included just under 730,000 operations. So Jon, for, for a few listeners that maybe are not familiar with the NJR, can you just give us some general details of the, of this data resource? And particularly in terms of the quality of data [00:03:00] capture, the type of information that you looked at? 

Yeah, sure. So the NJR it's the largest registry in the world and it captures primary and revision procedures in both the public and the private sector in England, Wales, Northern Ireland, the Isle of Man and Guernsey. It's mandatory for submission and the data capture is around 97% for primary hip and knee procedures. So it's a really good quality source of data. Absolutely. Yeah. And as I say, that amount of data capture, particularly for hip and knee replacement is, is, is very impressive, impressive. And so you had that data, obviously you collected it for that period of time. And so what analyses did you carry out? And I suppose quite important to that, what assumptions were made as part of this?

So we looked at the period of 2019. So that was taken as the baseline before COVID hit. Then we looked at 2020, 2021 and 2022. So lockdown started in March 2020, and restrictions [00:04:00] ended in around July 2021.

So that gave us around 18 months of data after the end of the pandemic. And what we did is we took 2019 as a baseline, and we made the assumption that the provision of joint replacements wouldn't change from that. And each year we then calculated what we termed the deficit, which is the amount of joint replacements that weren't done, had we had seen a continuation of 2019 volumes.

And then we broke the analysis down by the type of joint replacements, and then also we looked at each home nation specifically. And the last thing we did is we looked at the provision in the NHS and compared that to the independent sector. 

And just to say, say, Jon, the, the collection for the independent sector is quite complete as well. That's correct. 

Yes. Yeah. So the 97% includes the independent sector as well. Yeah. And that's a real strength of the NJR. And I should probably mention that if you look at the trends before 2019. In the decade or so before that, we were looking at an increase in joint replacements of [00:05:00] around 5 percent a year. And the projections are that that was going to continue to increase with our ageing population. So probably these estimates are underestimates of anything. 

Absolutely. Yeah, I think that's a very important point, isn't it? So, Jon, if we describe obviously how it was done. So in terms of the results of the study, what, firstly, what did you find in terms of the current deficit and how that had changed since the pandemic?

So in total we've lost around 160,000 procedures and that equates to just under three quarters of a year of normal operating. Mm-hmm . In terms of the deficit per year it was 47% down in 2020. Mm-hmm . 19% in 2021, and 5% in 2022. Yeah. So. I suppose the good news is that deficit is narrowing. But the bad news is that even in 2022, we hadn't done the same amount of operations as we were doing in 2019. So we're still actually falling behind. Absolutely. So it's still yet to recover those numbers. 

Absolutely. And how did that [00:06:00] vary in terms of type of joint replacement being formed? 

Quite a lot actually. So hips and elbows were relatively spared. So they lost around six months of procedures. Whereas the worst hit was in terms of absolute numbers was knees. So we lost around 95,000 knee replacements. So that's ten months of operating. And in terms of relative numbers, ankles are about 11 months behind. But the numbers are quite small for ankles comparatively. 

Absolutely. Was there any sort of, just before we move on, any, any thought about why hip, hip, hip, hip was more protected than knee at all, or?

Yeah, we thought about it. We don't have any definite answers, but if you look at the, the spared procedures relatively, elbows definitely are a large proportion of done for trauma. Yeah. And so that was maintained in pandemic above the elective indication. So that could explain elbows. Hmm. If you look at hip replacements, it's such a small minority that are done for trauma. Actually, [00:07:00] that doesn't bridge the gap between what we saw between hip replacements and knee replacements. So it must be to do with prioritization or the way that services are structured. If you look back to the 2019 data, already patients were waiting longer for knee replacements and hip replacements back then. So probably whatever's changed is kind of exacerbated the forces already at play. 

I see what you mean. Absolutely. And what was the variation seen between sort of the three home nations that you looked at? 

So again, there's wide variation there where we saw Wales and Northern Ireland hit considerably harder than England. Mm. So in Wales ,about 16 months of operating has been lost and in Northern Ireland, 15 months. So they've lost more than a year. And that's compared to eight months in England which is still bad, but relatively less. And then if you look at the the way that the deficit is recovering that's slower as well.

So in 22, England was, was five percent down, but Wales was still 25% down. So they've lost a [00:08:00] lot and unfortunately they're continuing to lose more. 

Yeah, absolutely. And I think that's quite interesting, isn't it, in terms of a provision of services in particular, but also in provision of services is you looked at the variation between the public and independent sectors and that, that was quite interesting, wasn't it?

Yeah, that was very interesting. And, unexpected, I think. So what we saw is in 2020, both sides were, were hit hard. And we saw a big reduction in numbers as you'd expect. Then in 2021 and 2022, what we've seen is the independent sector has really bounced back and expanded beyond 2019. So, In 2022, independent sector operating was up 127%. Whereas in the NHS it's still down at 70 something percent. Yeah. So what's that meant is that we've seen a, an inversion in, in just a few years where independent sector provision was around 40% in 20 19, and it's gone up to [00:09:00] 53% in 2022. So most joint replacements are now done in the private sector.

That's, that's an incredible figure, isn't it? And I know the, so the pandemic happened as the main driver of this, but that change of, of where you say that joint replacement now provision is now majority done in the, in the private sector is quite, it's quite a really start finding, I think, and, and, you know, in terms of all that, so you drag all that together, you do a very nice summary in terms of what these numbers mean in terms of what needs to be done to address these deficits. Can you just go through that, through that, through that for our listeners? 

Yeah, so we did some calculations based on, on the deficit incurred. And then if we were to hypothetically be able to expand services right now, how many years would it take until we were back to where we were in 2019? So if we could immediately expand today by ten percent of the operating we're doing, it would take us until 2031 to eliminate the deficit.

So to get [00:10:00] back to the 2019 when there was still four million patients on the waiting list. Yeah. And as you imagine, if you break it down by Wales and Northern Ireland, look at them specifically, they would require a larger expansion. So it would be 15% now to address their deficits within a decade.

Just to be clear, that's an immediate expansion on what the 2019 levels were or what the current levels were? Yes. Sorry. Yeah. 2019 levels. So we're still five percent behind then well, we were in 2022. 

In 2022 exactly. So it's an expansion on top of that, that rate. Absolutely. Exactly. And, and I think, again, I just, I found that very, very interesting, actually. And I think, so if we go on to sort of, you know, what all this means, you know, I think, you know, the strengths and importance of this data, I think I just, without doubt, clear, you know, with each and each a big data study, including analysis with national coverage of both, you know, it has independent and NHS providers of arthroplasty, mandatory data capture, as you said, to the NJR [00:11:00] and, you know, primary case attainment in excess of 90% for hip and knee arthroplasty in particular.

And I think the findings are, you know, are very sobering, you know, and highlighting the arthroplasty deficit following the pandemic is now equivalent to over two thirds of a year of normal operating activity, continues to increase. And even with those expansions in capacity from the 2019 level that you describe, it will still take years to rectify. I mean, it's, it's quite profound that I think, and how, how have you and your team sort of interpret these findings? And I suppose, was it what, was it to the degree you expected and the findings you expected?

So I think from personally for me and what you see in the clinical practice, I think we all knew that COVID has had a profound effect and patients are waiting longer.

But I think the overall findings are probably slightly worse than we expected in that I think we had expected that by 2022, we would at least be doing as much as we were in 2019. And, and the fact we're not [00:12:00] and still falling behind is, is probably slightly worse. Yeah. On top of that, I think the inequalities that are emerging between the nations, there's been some news coverage but again, they're slightly worse than we expected.

Yeah, I think that's very true. And I think you use that word 'inequality'. I think it is between the the nations as you see. And I suppose the other inequality is, is from the public to the private sector, isn't it? And in fact, that actually, if you can afford to pay, then actually your, your access is, is it will seem is actually potentially easier and quicker as we, as we would expect, but to such a degree, I was, I was quite surprised by that finding.

What I should mention is that although it's the the providers of change, of course, yes, it's still majority NHS-funded procedures. I'm with you. Absolutely. And we did look at the funding and that has seen a change, but it's not as dramatic. So we're seeing a a steady increase in the amounts of independently funded procedures.

Yeah. But the, the big explosion in the independent sector is NHS-funded. So choose a book. And that's a [00:13:00] very important point, isn't it? And I, yeah, caveat what I said, because obviously there is a, there is something there, but it's, it's amazing that returning capacity there as, as you've highlighted and in terms of, you know, how that fits with you know, you talk about data from Scotland and from the US and, and, you know, from Europe, it's not that dissimilar really, is it, in many ways? 

Yeah, yeah. So there are similarities and differences. So Scotland have they're separate from the NJR. They've got the Scottish Arthroplasty Project. And they've published their results up to the end of 23 now. So that's essentially a year, year more than we've got. And the picture is very similar, as you say, where you can see in 2022, it was still far below 2019. And even in 2023, Scotland hasn't recovered to 2019. And there was a really good piece in Bone & Joint Research about expansion in Scotland and a 20% expansion would still see patients waiting for, you know, one to two years for, for surgery.

Absolutely. So yeah, quite bleak there. And then just very briefly internationally, if you [00:14:00] look at US and Australian data from 2020, they saw big decreases, but actually their recovery has been a lot quicker. And their registries have even stopped reporting COVID, because presumably it's not an issue. Absolutely. Whereas Canada has been hit hard there, by the end of 21, they were still lagging behind. And they actually collect length of stay data and they've seen a hundred fold increase in, in day-case, hip and knee replacement since the pandemic. But even with that, they're still far down in terms of volumes.

That's really interesting to put all those different areas into context and different healthcare systems to a degree as well. I think that's really interesting. And in light of all that as well, Jon, I think, you know, we've obviously discussed the strengths of the study, which are, which are completely clear, but are there any sort of limitations or caveats to the data you would you would want to put out there?

Yeah, well, so I think the main limitation is that we've been talking about procedures lost, but actually these are just projections and we've made big assumptions that 2019 volumes would, would carry on. And we actually haven't [00:15:00] looked at demand. We're looking at purely provision. So how much we're doing and as we've mentioned, probably there are factors which might make estimates conservative, such as the fact that the provision was projected to increase.

Yeah. On top of that, when we see patients with long waits, they're often anesthetically more complicated, more frail, and surgically more complicated. So you can get a a knock-on effect in a vicious cycle where, where patients are, the cases are taking longer and that's exacerbating the issue.

Yeah, definitely. I mean, that's certainly something I hear from my arthroplasty colleagues here in Edinburgh is actually the deconditioning and the length of time that people are having to wait, that they are frailer patients and more complex procedures and worse arthritis, all those sorts of things.

So it's, it's difficult, isn't it? And so maybe to finish up, Jon, and, you know, in reality, you know, we talk about those projections that you talk about or what the expansion would need to be, should I say, is it felt that this can really be achieved given, you know, the current strains and pressures on the healthcare service that we have at the moment and restricted resources? Is it possible? What other options [00:16:00] out there that could maybe make it easier or better or to achieve? 

Yeah, well, I think these big questions and, and difficult to answer, especially for us as surgeons. And I think maybe that's why I started talking about who is a PM at the start, because I think a lot of the answers will come from policy and politics.

So what we did in the papers, we tried to, you know, put it all into context. So we talk about a ten percent expansion. We'll see us recovered by 2031 and ten percent sounds doable. But if you think about it in terms of that's like every hospital in the country doing five weeks of extra operating a year. So that's a lot of weekends. Absolutely. Or it's equivalent to building about 20 high-volume surgical hubs, which do 500 hips and 500 knees a year. And again, it's, it's a pretty big infrastructure change. So whether it's achievable I'm not sure. In the meantime, there are plans to continue to expand into the private sector. And we've talked about [00:17:00] inequalities. And I think the other thing is geographical where independent hospitals are built where the money is. And so affluent patients will have the option of choosing book, by virtue of living in the area. Yeah. So that could still exacerbate the inequalities there.

And I guess, secondly, is an issue, I'm a registrar, issue close to my heart, which is training. And the fact that we now have the majority of joint replacements well, not easily accessible to trainees is, is a big barrier to training. And potentially I wonder whether we'll see changes there. And then on top of that, knock-on effect is NHS patients are more frail and complex surgically, anesthetically, all of which increases pressure on training.

Absolutely. You know what, well said Jon, I think that's very true. And I think it sort of highlights all those, those potential issues, but you know, we can but try and try for our patients and well Jon I'm afraid that's all we have time but but thank you so much taking time to join me and and highlighting I think a really important paper and I think not [00:18:00] only obviously for our specialty and for those who make policy but I think most importantly for our patients because I think it really advocates for our patients and what they're having to go through in terms of the waits that they're having to go through and the demand that is out there for the for our services so thanks so much Jon for joining us it was great.

Oh, thank you very much for having me.

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