prove most effective in reducing public anxiety and concerns over the safety of resuming elective 23
Keywords: COVID-19; elective surgery; public perceptions 25 26 27
Introduction 28 29
While the United States (US) healthcare system has united to meet the challenges of the 30 coronavirus disease 2019 pandemic, this effort has placed many hospitals and 31
health systems under significant financial pressure [1] [2] [3] [4] [5] . A recent report estimated that this 32 pandemic has resulted in over $202 billion in losses to US health systems and hospitals 1 , much 33 of which is due to the cessation of elective surgery 1, 3 . As the COVID-19 burden decreases, 34 many health systems are increasingly eager to resume margin producing elective surgery in a 35 safe and controlled manner [6] [7] [8] . A new set of challenges, however, present themselves with the 36 resumption of elective care 5, 9 . Health systems may be at a crossroads between the public health 37 obligation to keep the population healthy and safe, and the financial solvency concerns about 38 withstanding this pandemic 1, 6, 10 . 39 40 It is unclear how patients will react to the resumption of elective surgery. While early reports 41 have demonstrated that most patients seem eager to have their procedures done, others are 42 hesitant 11 . Resuming elective surgery safely and at a responsible time may still result in financial 43 losses and suboptimal patient outcomes if the public's perceptions and subsequent treatment 44 choices are not considered. Patients preferring to undergo surgery soon after health systems 45 reopen may be at a higher risk of postoperative morbidity and mortality. Alternatively, 46 47 disparities in disadvantaged and vulnerable populations 12-15 . 48 49 Currently, there is limited data to guide health systems in the resumption of elective surgeries 7 . 50
Without a true understanding of the public's beliefs and concerns over the safety of resuming 51 elective care, healthcare organizations may be flying blind in deciding how to optimize processes 52 to reduce the fear of infection. In this context, we used an online crowdsourcing platform to 53 explore public perceptions and concerns towards resuming elective surgery during the COVID-54 19 pandemic, and to determine factors associated with the timing of preferred surgery after 55 Personal funds were used to award participants. Incomplete surveys were excluded from the 95 analysis. The survey was administered over a two-day period during May 2020. A sensitivity 96 analysis was performed for participants over the age of 60, as they represent a considerable 97 portion of the population undergoing elective orthopaedic surgery. 98 99
We performed a bivariate analysis to identify population characteristics associated with 101 preferring early elective-surgery (within one month of health systems resuming elective surgery). 102 A Pearson's chi-squared test (or Fisher's exact test when appropriate) was used for each variable. 103
We then placed all variables with P < 0.1 from the bivariate analysis into a multivariable 105 regression model to identify which population characteristics were independently associated with 106 preferring early surgery. Variables were considered using an enter selection method. The results 107 are presented as adjusted odds ratios (OR) with 95% confidence intervals (CI). A threshold of P 108 < 0.05 was used to delineate statistical significance. 109 110
Overall, 776 participants completed our survey. After excluding surveys with incomplete data, 112 722 responses remained for final analysis. Demographic data of our sample population is 113 reported in Table I.  114 115 Most (61.1%) participants were concerned (answered "somewhat" or "to a great extent") with 116 contracting COVID-19 during the surgical process, while 58.6% were worried that they would 117 expose family members (Table II) . Concern centered around the check-in process and waiting 118 room areas (39.9%), as well as excessive interactions with staff (25.5%). Overall, 56.6% of 119 participants preferred to have their procedure performed at a hospital rather than at an outpatient 120 surgery. These respondents were more likely to be male (57.6% vs. 42.4%; P < 0.001), native 131
English speakers (96.9% vs. 92.3%; P = 0.028), earn less than $30,000 annually (34.6% vs 132 25.2%; P = 0.047) and have Veterans Affairs as their primary health insurance (4.2% vs. 0.6%; P 133 < 0.001) (Table III) . 134
After controlling for potential confounding effects in the multivariable regression model (Table  136 III), the population characteristics independently associated with feeling comfortable undergoing 137 early elective surgery included male sex (OR, 1.9; 95% CI, 1.3-2.7; P < 0.001), native English 138 speaking (OR, 2.6; 95% CI, 1.04-6.4; P = 0.042), and Veterans Affairs insurance (OR, 4.5 139 reference: Medicare; 95% CI, 1.1-18.7; P = 0.036). 140
Of note, there was no association between a preference towards early surgery and age (P = 142 0.086), geographic region of residence (P = 0.057), perceived overall health status (P = 0.344), or 143 marital status (P = 0.722). Furthermore, race (P = 0.637), a history of major depressive disorder 144 (P = 0.412), health literacy (P = 0.488), and patient engagement (P = 0.608) were not predictive 145 of the timing of preferred surgery. 146 147
As the COVID-19 burden declines and society slowly reopens, health systems are beginning to 149 resume elective procedures. A clear understanding of the public's beliefs regarding the 150 resumption of elective surgery may help guide health systems in providing patients with 151 equitable, efficient, and safe care while also optimizing financial stability through this transition 152 period. In this context, we used an online crowdsourcing platform to explore public perceptions 153 and concerns towards resuming elective surgery during the COVID-19 pandemic, and to 154 determine factors associated with the timing of preferred surgery after health systems reopen. 155
The primary strengths of this study include its large sample size and the novel use of an online 157 crowdsourcing platform to obtain survey responses. The rapid evolution and daily changes 158 occurring throughout the COVID-19 pandemic has created an information lag in the medical 159 community 26 . The nature of the pandemic has resulted in many clinical decisions being made 160 with a dearth of quality evidence [27] [28] [29] . Clinical trials cannot be conducted fast enough to maintain 161 pace with the rate of change. The ability of MTurk to obtain reliable, consistent, and 162 generalizable survey responses significantly faster and with decreased costs compared to 163 traditional methods makes its use for data collection during the COVID-19 pandemic and beyond 164 opportune 20, 22 . 165 166 Despite its strengths, our study was not without limitations. The primary weakness of this study 167 is the lack of preexisting symptomatic pathology in our study population. An expectant approach 168 towards surgery may be less likely in patients coping with disabling musculoskeletal conditions. 169
However, the beliefs of our cohort are a reasonable proxy to use in this case for several reasons. 170
Multiple prior survey studies have used the general public as a proxy to understand the 171 perceptions of patients choosing to undergo elective surgery 30, 31 . Furthermore, the MTurk 172 platform has been extensively evaluated and is thought to have arguably closer generalizability 173 to the US population than results derived using traditional survey methods 20, 32 . Another 174 weakness of the study is that certain MTurk users may have chosen to not participate in the 175 study. It is unknown whether the demographics of this group differed from our sample 176 population. Lastly, the higher computer literacy of our sample population may have biased their 177 responses towards favoring telehealth for their postoperative care. 178
We found that men strongly favored early surgery, while women demonstrated a preference 180 towards delaying surgery. Interestingly, this same trend has been reported in regards to patients 181 undergoing total joint arthroplasty (TJA) prior to the COVID-19 pandemic 33 . Gender bias, 182 specifically in the form of surgeons being less likely to recommend TJA and including fewer 183 shared decision-making elements to women 34, 35 , may play a role in this phenomenon. However, 184
other studies have demonstrated that the values influencing the decision to undergo surgery may 185 also differ between sexes and contribute to this trend 33 . Specifically, a study by Karlson et al. 186 described that the women with knee osteoarthritis overwhelmingly chose to delay undergoing 187 total knee arthroplasty longer than men due to more concerns of a bad outcome, the hope for 188 improved future technology, and their perceived caregiver responsibilities 33 . Men conversely 189 preferred earlier surgery as they wanted to return to a high functional level sooner, were more Low patient engagement⨏ 79 (10.9) *Defined as Patient Health Questionnaire-2 (PHQ-2) score of 3 or greater. †Defined as answers of "somewhat/a little/not at all" to the Single Health Literacy Screening Question.
⨏Defined as an answer of "not very confident" to the Single Health Confidence Question. ⨏Defined as an answer of "not very confident" to the Single Health Confidence Question.