Acta Orthopaedica - 2026-05-09 - Journal Article; Comparative Study
No difference in patient-reported outcome measures between private and public hospitals in the Netherlands: a cross-sectional analysis based on 170,150 hip and knee arthroplasties from the Dutch Arthroplasty Register.
Vink MC, Bos P, Van Dooren BJ, Peters RM, Van Steenbergen LN, De Visser E, Brinkman JM, Schreurs BW, Zijlstra WP
Topics
Key Takeaway
Across 170,150 primary hip and knee arthroplasties in the Netherlands, PROM differences between private and public hospitals were statistically significant on only a subset of measures but all absolute differences were ≤1.3 points—well below any established minimal clinically important difference.
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Summary
This cross-sectional registry analysis from the Dutch Arthroplasty Register (LROI) compared PROMs (NRS pain, EQ-5D-5L, HOOS/KOOS-PS, OHS/OKS) between private and public hospitals for primary THA, TKA, and UKA performed 2014–2023, using mixed-effects models adjusted for age, BMI, ASA class, and socioeconomic status. At 3 months, public hospitals showed statistically significant but clinically negligible advantages in HOOS/KOOS-PS for all three procedure types (mean differences 0.5–1.3 points) and OKS for TKA and UKA, while private hospitals showed a marginal NRS pain advantage for TKA (−0.2). Mean travel distance was shorter for public hospital patients, indicating private hospitals did not improve geographic access to care.
Key Limitation
The healthier baseline profile of private hospital patients (younger, lower BMI, lower ASA class) represents residual case-mix confounding that statistical adjustment cannot fully eliminate, meaning apparent outcome equivalence may partly reflect patient selection rather than equivalent surgical quality.
Original Abstract
BACKGROUND AND PURPOSE
Private hospitals have become more frequent healthcare providers for arthroplasty surgery in the Netherlands. The aim of our study was to assess patient-reported outcome measures (PROMs) in patients who received primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) in private hospitals compared with patients from public hospitals, and to assess access to care based on mean travel distance to the healthcare facility.
METHODS
Patients operated on between 2014 and 2023 were included. Patient characteristics, preoperative, 3- or 6-, and 12 months postoperative PROMs (Numeric Pain Rating Scale [NRS] pain, EuroQoL 5-Dimensions [EQ-5D-5L], Hip disability and Osteoarthritis Outcome Score [HOOS-PS], Knee Injury and Osteoarthritis Outcome Score [KOOS-PS], Oxford Hip Score [OHS], and Oxford Knee Score [OKS]) were retrieved from the LROI. For analysis, repeated measurements were performed, using mixed-effect models adjusted for confounders. Primary endpoints for inference were NRS pain during activity, HOOS/KOOS-PS, and OHS/OKS at 3 months follow-up. Mean travel distance to the hospital was compared, as measure for access to care.
RESULTS
146,303 primary THAs, TKAs, and UKAs performed in public hospitals and 23,847 in private hospitals were included. Patients undergoing arthroplasty in private hospitals were generally younger and had a higher socioeconomic status and lower body mass index and American Society of Anesthesiologists Physical Status class. Both patients from private and public hospitals improved similarly and significantly after surgery. At 3-month follow-up, public hospitals showed marginal but statistically significant advantages in HOOS/KOOS-PS for THA, TKA, and UKA (mean differences 0.5 [95% confidence interval (CI) 0.1-0.9], 0.5 [CI 0.1-0.9], and 1.3 [CI 0.5-2.1], respectively). OKS favored public hospitals for TKA and UKA (-0.4 [CI -0.6 to -0.2] and -0.6 [CI -1.0 to -0.1]). NRS pain during activity favored private hospitals for TKA (-0.2 [CI -0.3 to -0.1]). All absolute differences were small and without statistical significance. Mean travel distance was significantly shorter for patients treated in public hospitals.
CONCLUSION
There is no difference in PROMs between public and private hospitals after primary THA, TKA and UKA in the Netherlands. Based on mean travel distance, access to care was not compromised for high-risk patients.