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Assessing social disparities in inpatient vs. outpatient arthroplasty: a in-state database analysis

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Abstract

Introduction

Given the growing emphasis on patient outcomes, including postoperative complications, in total joint arthroplasty (TJA), investigating the rise of outpatient arthroplasty is warranted. Concerns exist over the safety of discharging patients home on the same day due to increased readmission and complication rates. However, psychological benefits and lower costs provide an incentive for outpatient arthroplasty. The influence of social determinants of health disparities on outpatient arthroplasty remains unexplored. One metric that assesses social disparities, including the following individual components: socioeconomic status, household composition, minority status, and housing and transportation, is the Social Vulnerability Index (SVI). As such, we aimed to compare: (1) mean overall SVI and mean SVI for each component and (2) risk factors for total complications between patients undergoing inpatient and outpatient arthroplasty.

Methods

Patients who underwent TJA between January 1, 2022 and December 31, 2022 were identified. Data were drawn from the Maryland State Inpatient Database (SID). A total of 7817 patients had TJA within this time period. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). The mean SVI was compared between inpatient and outpatient procedures for each themed score. The SVI identifies communities that may need support cause by external stresses on human health based on four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. The SVI uses the United States Census data to rank census tracts for each individual theme, as well as an overall social vulnerability score. The higher the SVI, the more social vulnerability, or resources needed to thrive in that area. Multivariate logistic regression analyses were performed to identify independent risk factors for total complications following TJA after controlling for risk factors and patient comorbidities. Total complications included: infection, aseptic loosening, dislocation, arthrofibrosis, mechanical complication, pain, and periprosthetic fracture.

Results

Patients who had inpatient arthroplasty had higher overall SVI scores (0.45 vs. 0.42, P < 0.001). The SVI scores were higher for patients who had inpatient arthroplasty for socioeconomic status (0.36 vs. 0.32, P < 0.001), minority status and language (0.76 vs. 0.74, P < 0.001), and housing and transportation (0.53 vs. 0.50, P < 0.001) compared to outpatient arthroplasty, respectively. There was no difference between inpatient and outpatient arthroplasty for household composition and disability (0.41 vs. 0.41, P = 0.99). When controlling for comorbidities, inpatient arthroplasty [Odds Ratio (OR) 1.91, 95% Confidence Interval (CI) 1.23–2.95, P = 0.004], hypertension (OR 2.11, 95% CI 1.23–3.62, P = 0.007), and housing and transportation (OR 2.00, 95% CI 1.17–3.42, P = 0.012) were independent risk factors for total complications.

Conclusion

Inpatient arthroplasty was associated with increased social disparities across several components of deprivation as well as an independent risk factor total complications following TJA. To the best of our knowledge, this study is the first to examine the negative repercussions of inpatient arthroplasty through the lens of social disparities and can target specific areas for intervention.

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Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, 2401 West Belvedere Avenue, Baltimore, MD, 21215, USA

    Jeremy Dubin, Sandeep Bains, Ruby J. Gilmor, Daniel Hameed, James Nace, Michael Mont & Ronald E. Delanois

  2. Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA

    Mark LaGreca

  3. Department of Orthopaedic Surgery, St. Luke’s University Health Network, Bethlehem, PA, USA

    Douglas W. Lundy

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  1. Jeremy Dubin
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  2. Sandeep Bains
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  3. Mark LaGreca
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  6. James Nace
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  7. Michael Mont
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Contributions

All authors contributed to the study conception and design, material preparation, data collection and analysis, first draft of the manuscript and all authors commented on previous versions o the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ronald E. Delanois.

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Conflict of interest

Authors A, B, C, D, E, and H have no conflicts of interest. Author F receives research support from Arthritis Foundation: Board or committee member, Journal of Arthroplasty, Journal of the American Osteopathic Medicine Association, Orthopedic, Knowledge Online: Editorial or governing board, Journal of Knee Surgery: Editorial or governing board, Knee: Editorial or governing board, Microport: Paid consultant; Paid presenter or speaker; Research support, Stryker: Research support United: Research support. Author G receives consultant fees from Stryker 3MCentrexion CERAS Health Johnson & Johnson Kolon Tissuegene MirrorAR NXSCI Pacira Peerwell Pfizer Lily Skye Biologics SOLVD Health Smith & Nephew, payments for lectures from Stryker, leadership role for The Knee Society The Hip Society Journal of Arthroplasty Journal of Knee Surgery Surgical Technology International Orthopaedics and stock options from CERAS Health MirrorAR Peerwell USMI. Author I receive research support from Baltimore City Medical Society.: Board or committee member, Biocomposites, Inc.: Research support, CyMedica Orthopedics: Research support, DePuy Synthes, Product, Inc.: Research support, Flexion Therapeutics: Research support, Microport Orthopedics, Inc.: Research support, Orthofix, Inc.: Research support, Patient-Centered Outcomes Research Institute (PCORI): Research support, Smith & Nephew: Research support, Stryker: Research support, Tissue Gene: Research support, United Orthopedic Corporation: Research support.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Institutional review board approval was not required for this study as the data were retrieved from a deidentified database.

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Dubin, J., Bains, S., LaGreca, M. et al. Assessing social disparities in inpatient vs. outpatient arthroplasty: a in-state database analysis. Eur J Orthop Surg Traumatol (2024). https://doi.org/10.1007/s00590-024-03922-w

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