JOA - 2026-05-21 - Journal Article
Socioeconomic Disparities in Outcomes Following Primary Total Hip Arthroplasty: A Large Database Analysis of 2,280,000 Procedures.
Ahmadi A, Podder D, Richards M, Parisier E, Zelazny D
Topics
Key Takeaway
Medicaid and self-pay patients undergoing primary THA face 36% and 50% higher adjusted odds of in-hospital complications, respectively, compared to privately insured patients across 2.28 million weighted procedures.
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Summary
This retrospective database study examined the association between socioeconomic status—defined by ZIP-code income quartile and payer type—and in-hospital outcomes following elective primary THA from 2016–2021. Multivariable logistic regression adjusted for age, sex, race, and comorbidity burden showed Medicaid (OR 1.36) and self-pay (OR 1.50) patients had significantly higher complication risk, while Medicare (OR 0.84) and Medicaid (OR 0.89) patients had lower odds of routine home discharge versus private insurance. Paradoxically, lowest-income quartile patients had higher adjusted odds of home discharge (OR 1.42) than highest-income patients, likely reflecting differential access to post-acute care facilities.
Key Limitation
Index-admission-only capture excludes 30- and 90-day readmissions, reoperations, and post-discharge complications—the outcomes most sensitive to socioeconomic barriers in post-acute care access.
Original Abstract
BACKGROUND
Total hip arthroplasty (THA) is one of the most common and cost-effective orthopaedic procedures in the United States, yet disparities in access, complication rates, and discharge disposition persist across socioeconomic groups. Although racial disparities after THA are well described, the influence of socioeconomic status (SES)-particularly income and insurance type-on in-hospital outcomes during the index admission remains less clearly defined. Clarifying these relationships is essential for improving equity in joint arthroplasty care.
METHODS
A retrospective cohort study was conducted using a large national database to identify adults undergoing elective primary THA from 2016 to 2021. Approximately 2.28 million weighted THA cases were included in the analysis. The SES indicators included ZIP-code-based income quartiles and primary payer category (e.g., private, Medicare, Medicaid, self-pay, and other). Survey-weighted descriptive statistics characterized demographic and clinical patterns. Multivariable logistic regression, adjusted for age, sex, race, comorbidity burden, and admission type, evaluated associations between SES and prolonged length of stay (LOS), discharge disposition, in-hospital complications, and mortality.
RESULTS
Routine home discharge declined from 38.6% in the lowest income quartile (Q1) to 33.6% in the highest (Q4), with Q1 patients demonstrating higher adjusted odds of home discharge (odds ratio (OR) 1.42, 95% confidence interval (CI) 1.33 to 1.51, P < 0.001). Medicare (OR 0.84, P < 0.001) and Medicaid (OR 0.89, P < 0.001) coverage were associated with reduced odds of home discharge compared with private insurance. Income quartile did not significantly predict perioperative complications; however, Medicaid (OR 1.36, P < 0.001) and self-pay (OR 1.50, P < 0.01) patients had increased risk. In-hospital mortality was rare (< 0.2%), with elevated odds in lower-income groups largely attributable to comorbidity severity. Lower SES and public insurance coverage were also associated with modest increases in LOS.
CONCLUSIONS
Socioeconomic disadvantage influences inpatient outcomes following THA. Lower-income and publicly insured patients experience longer hospitalizations, higher complication risk, and distinct discharge patterns. Incorporating social and payer-based risk factors into perioperative planning and value-based payment models may improve equity in joint arthroplasty care.