Introduction 82 The coronavirus disease 2019 disease continues to spread, with almost 2.5 million 83 confirmed cases and over 169,000 deaths attributed to the disease as of April 20, 2020 [1, 2] . On 84 March 11, 2020, the World Health Organization (WHO) issued a statement characterizing 85 COVID-19 as a worldwide pandemic and warning governments to take expedient action [3] . 86 This global health crisis has already disrupted all aspects of society, with safety and economic 87 concerns radiating across the world. As part of the international collaboration to flatten the 88 number of emerging cases, multiple organizations have released guidelines related to the 89 cessation of elective surgical procedures [4] [5] [6] [7] . In light of the increased utilization of healthcare 90 associated with the disease, these guidelines have left providers and stakeholders increasingly 91 concerned regarding the true financial impact COVID-19 will have on the healthcare system 92 [8, 9] . 93 In response to this growing financial strain, the American Medical Association (AMA), 94 American Hospital Association (AHA), and the American Nurses Association (ANA) wrote a 95 unified message to Congress requesting $100 billion to help cover the excessive costs associated 96 with COVID-19 treatment, as well as the lost revenue caused by the suspension of elective 97 surgical procedures [10, 11] . Although the Coronavirus Aid, Relief, and Economic Security 98 (CARES) Act provided these funds to hospitals and healthcare providers [12, 13] , the rapid 99 decrease in elective surgical procedures will undoubtedly continue to economically impact 100 healthcare systems that previously relied on these stable sources of revenue. Additionally, 101 hospitals must prepare for the surge in procedural demand expected to follow the current 102 pandemic. While there is limited information available for providers and governing bodies at this 103 time, understanding how public interest for elective procedures has changed during the recent crisis can help policy makers understand these potential future financial losses and surges in 105 healthcare demand. Given that total joint arthroplasty (TJA) remains one of the most commonly 106 performed elective procedures in the United States (US) [14] , interest in TJA likely serves as an 107 appropriate model to obtain this information. cases. In times of urgency or crisis, primary data sources are often unavailable. A successful 111 tool, however, to study the epidemiology of disease outbreaks and public consciousness alike has 112 been the Google Trends analytics platform [15] [16] [17] [18] . Regarding the present pandemic, the tool is 113 already being utilized to map the prevalence of symptoms related to COVID-19 and predict 114 hotspot regions before they overtly emerge [19] [20] [21] . The purpose of this study was to use the 115 Google Trends analytics platform to quantify the impact COVID-19 on the relative public 116 interest in elective TJA.
The Google Trends analytics platform was utilized to determine the Google Search Volume The terms "Knee Replacement," "Hip Replacement," and "Orthopedic Among the general public, these keywords were discovered to have a much higher usage than 130 terms such as "Arthroplasty" or "Total Joint Replacement." We implemented searches for both 131 "Orthopaedic" and "Orthopedic" to expand the scope of our analysis but determined the latter 132 keyword to have an over 16-fold higher utilization in the US. To account for the current shift of 133 elective surgeries, the string "elective surgery cancellation" was analyzed.
For each search term, weekly GSVI data was extracted for all 50 states and the District of 135 Columbia between April 1, 2015 and April 4, 2020. Time series analysis was conducted using 136 validated statistical process control (SPC) methodology. An average moving range was 137 calculated across the entirety of the study period. This value was used to construct control limits, 138 which closely approximate three standard deviations above and below the mean. The purpose of 139 these limits is to differentiate between random and special cause variation, the former being 140 defined as fluctuation within the upper and lower boundaries. These methods are commonly used 141 to track the stability of large datasets across many industries [30] [31] [32] [33] [34] [35] [36] .
In addition to the SPC analysis, individual states were compared to determine those with 143 the lowest interest in TJA during the first four months of 2020. The states identified to have the 144 lowest GSVI values were compared against states with the highest number of COVID-19 cases 145 and against states experiencing the greatest increase in new unemployment claims filed [37, 38] .
States were then stratified by the severity of the public health policies adopted by local 147 governments as well as by U.S. Census Region to assess for regional variation [39, 40] . (Table 1) . For 165 each search term, the drop in GSVI values observed during March of 2020 breeched the lower 166 control limit, approximating three standard deviations below the five-year mean. According to 167 standard SPC methodology, this drop signifies a non-random variation in the GSVI data. The 168 decline was the most significant for "Knee Replacement" searches, followed by "Hip 169 Replacement" and "Orthopedic Surgeon" searches, respectively. A concurrent spike was (Table 3) (Table 4 ). However, these findings similarly did not reach the level of statistical significance. truly deferring care-seeking behavior to adhere to with social distancing protocols. Irrespective 211 of the reason, these results represent a decline in elective TJA case volume and subsequent 212 financial strain on many hospitals, particularly those serving critical-access functions.
Our study is most clearly limited by the use of GSVI values as a proxy for public interest 214 in elective TJA and as a predictor for distal healthcare economic trends. Additionally, our 215 analysis included a relatively short time frame and did not, therefore, account for longer term 216 trends in the online search queries of potential patients. However, given the rapid progression of 217 COVID-19, we would suggest that real-time data regarding its impact on current and future elective surgery remain crucial. The degree to which Google Trends data such as the GSVI truly 219 represent current consumer behavior and sentiment around elective TJA. Notably, we were 220 unable to capture queries related to additional search engines and could not control for the 221 possibility of patients seeking TJA information elsewhere. Furthermore, although elderly patients 222 are more likely to seek surgical management for osteoarthritis, it is possible that this patient 223 population may be less accustomed to using technological services [42] . Granted that Google 224 receives over 2 trillion queries a year [43], however, our study population likely serves as an 225 adequate sample of those seeking health information on the internet [44].
One growing concern across the orthopaedic community is the potential surge in TJA Medicaid, as well as for hospital systems nationwide. However, now that there has been a delay 231 in care for months, the pent-up demand for TJA will result in a greater burden on the healthcare 232 system with subsequent delays in care, as providers attempt to catch-up with this increased need. parity laws in order to ensure the wide telehealth services may very well be warranted.
The present study provides a unique evaluation of online search queries related to TJA 258 and demonstrates their rapid decline during the COVID-19 pandemic. We have found a drastic 259 decrease in the relative popularity of google searches for hip and knee replacements both 260 nationally and worldwide. Granted that patients suffering from osteoarthritis will continue to 261 need care after the current crisis is controlled, the possible pent-up demand could result in a 262 greater volume and economic burden that our present healthcare system may be able to withstand. This, in turn, could translate to a bottleneck of care for many orthopaedic patients.
Public interest in TJA should continue to be followed in real-time, nationally and globally, as the 265 pandemic progresses. Further research is required to inform physicians, patients, the government, 266 insurers, and other key stakeholders on how best to proceed through the COVID-19 pandemic.
Focus should be on maintaining patient and physician safety, ensuring continued access, and 268 analyzing preparedness for sudden fluctuations in both the supply and demand of care. . *Policy data accurate as of April 7, 2020. "Limited action" refers to public advocacy around social distancing and hygiene measures, without mandatory restrictions. "Social distancing" refers to voluntary quarantine directives with the closure of schools, bars, and restaurants. "Stay at Home Order" refers to mandatory quarantine and suspension of all nonessential business and activities. . *Policy data accurate as of April 7, 2020. "Limited action" refers to public advocacy around social distancing and hygiene measures, without mandatory restrictions. "Social distancing" refers to voluntary quarantine directives with the closure of schools, bars, and restaurants. "Stay at Home Order" refers to mandatory quarantine and suspension of all non-essential business and activities.