Benjamin Domb, MD, founder and medical director of the American Hip Institute & Orthopedic Specialists in Des Plaines, Ill., is an advocate of lifting restrictions on procedures deemed elective.
With nearly a dozen states doing just that, Dr. Domb told Becker's Spine Review how American Hip Institute is resuming cases and what orthopedic groups can expect as they proceed.
Note: Responses were lightly edited for length and style.
Question: Do you think practice volumes will bounce back to normal levels when orthopedic groups resume elective cases? Why or why not?
Dr. Benjamin Domb: We'll certainly shift to a "new normal" as restrictions are lifted, in terms of best practices and the overall patient experience, but I do believe care facilities can get back to regular patient volumes. The need for standard care does not stop, and both medical professionals and patients will feel more comfortable with the transition after the following steps take place:
1. Hospitals and care facilities adopt new policies and practices. There is often a lag between the issuance of government guidance and when facilities act on it, but lag time must be reduced with organizations and medical professionals acting immediately.
2. Physicians return to providing care. Medical professionals took an oath to protect others, and we physicians must do just that for the many who have been left undertreated.
3. Patients choose to pursue care. This is a personal decision, not a one-size-fits-all answer. Every patient should feel empowered to make his or her own educated decision about whether to pursue or further postpone care, with physician guidance.
Q: What factors will affect orthopedic practice volumes in the next four to six weeks?
BD: At American Hip Institute, we expect to perform twice as many surgeries as usual in May and June to accommodate all the patients whose care was delayed due to being considered "elective." The lifted ban contributes to this volume as people are more comfortable moving forward with a standard procedure, but [volumes will also be affected by] the deleterious effects of procedure delays that were more insidious. Patients may have suffered compensatory injuries to other parts of their body that will now need to be treated on top of their original issue.
Q: Health experts are projecting a second wave of COVID-19 in the U.S. Do you foresee a corresponding second wave of elective procedure restrictions?
BD: The medical community and everyday Americans have seen the negative effect of sweeping bans on elective procedures and its potential to cause a secondary health crisis. In the event of a second wave of COVID-19, it's my hope that we'll be better prepared to ensure non-COVID-19 patients still get the care they need.
We must take every precaution possible to continue minimizing the risk of COVID-19 transmission everywhere in society, especially in the healthcare facility. The American Hip Institute was very early to adopt preventive measures, including social distancing, routine cleaning and sterilization of all workspaces and patient areas, use of masks and gloves, and minimization of direct contact. I believe many of these measures will become the norm in all healthcare facilities, and that this will lead to a permanent and positive change.
Q: What's the biggest challenge right now when it comes to reopening practices and determining which cases to proceed with?
BD: Certain procedures should and will be prioritized over others as the ban on elective surgeries is lifted in the coming weeks. The driving force behind prioritization must be the impact on a patient’s health with delay in care. Treatments of fractures and acute tears of tendons or ligaments are often urgent procedures. To delay such procedures further may render the injury irreparable, and therefore, orthopedic surgeons such as myself will prioritize these surgeries.
We must empower patients to decide whether their procedures should proceed or be postponed further. As we receive federal and state guidance updates, it is incumbent upon physicians to make ourselves available to provide care, while diligently educating our patients about the potential risks of procedures during the COVID-19 crisis. We must help the patient balance those risks against the risk of delaying their procedure.
Q: How will resuming elective cases be different in orthopedics compared to other specialties?
BD: At American Hip Institute specifically, we perform many of our surgeries at an ASC dedicated to orthopedics. Orthopedic patients are typically healthy and are exposed to very small numbers of healthcare workers or other patients in these centers. There is only orthopedic equipment, which does not have any exposure to surgical equipment used for treatment of infections.
We have long known that the risk of [facility-borne] infections is much lower in an ASC than in the hospital. Up to 1 to 2 percent of patients undergoing a hip replacement in a hospital setting will develop an infected hip after surgery. Data from the American Hip Institute suggests performing outpatient hip replacement in the ambulatory surgery setting can reduce the rate of postoperative infection to as low as 0.1 percent.
One dramatic change I expect is an acceleration of the migration of care from hospitals to outpatient facilities. Heightened concern for infection in our society will cause both patients and doctors to prefer care in an outpatient center with lower infection risk.
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