Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007–2014

Abstract

BackgroundTotal hip arthroplasty (THA) is one of the most widely performed surgical procedures in the USA. Safety net hospitals, defined as hospitals with a high proportion of cases billed to Medicaid or without insurance, deliver a significant portion of their care to vulnerable populations, but little is known about the effects of a hospital’s safety net burden and its role in healthcare disparities and outcomes following THA. We quantified safety net burden and examined its impact on in-hospital mortality, complications and length of stay (LOS) in patients who underwent THA.MethodsWe analyzed 500 189 patient discharge records for inpatient primary THA using data from the Healthcare Cost and Utilization Project’s State Inpatient Databases for California, Florida, New York, Maryland and Kentucky from 2007 to 2014. We compared patient demographics, present-on-admission comorbidities and hospital characteristics by hospital safety net burden status. We estimated mixed-effect generalized linear models to assess hospital safety burden status’ effect on in-hospital mortality, patient complications and LOS.ResultsPatients undergoing THA at a hospital with a high or medium safety net burden were 38% and 30% more likely, respectively, to die in-hospital compared with those in a low safety net burden hospital (high adjusted OR: 1.38, 95% CI 1.10 to 1.73; medium adjusted OR: 1.30, 95% CI 1.07 to 1.57). Compared with patients treated in hospitals with a low safety net burden, patients treated in high safety net hospitals were more likely to develop a postoperative complication (adjusted OR: 1.11, 95% CI 1.00 to 1.24) and require a longer LOS (adjusted IRR: 1.06, 95% CI 1.05, 1.07).ConclusionsOur study supports our hypothesis that patients who underwent THA at hospitals with higher safety net burden have poorer outcomes than patients at hospitals with lower safety net burden.

Association of Hospital Safety Net Status With Outcomes and Resource Use for Extracorporeal Membrane Oxygenation in the United States

“…La et al found that high safety net burden hospitals were 38% more likely to die after total hip arthroplasty, 11% more likely to develop postoperative complications, and had longer hospital length of stay. 26 Following coronary artery bypass grafting or valvular procedures, SNH has been implicated to have poorer odds of failure to rescue after development of septicemia or tamponade. 15 Persistent demonstration of such adverse findings, even after risk adjustment for patient level characteristics, point to the presence of systemic disparities at SNH, which may serve as barriers to the delivery of high value care.…”

Implementation of an enhanced recovery protocol at a safety net hospital

“…10 Therefore, this cohort tends to be of low socioeconomic status with suboptimally managed medical comorbidities, more housing insecurities, and higher rates of substance abuse. 11 - 14 Additionally, these patients have been shown to experience higher rates of arthritis, 12 worse quality of life while waiting for surgery, 15 longer hospital length of stay (LOS), and more complications after arthroplasty. 13 , 14 , 16 The suspension of arthroplasty procedures, therefore, created a tremendous backlog of arthroplasty patients with neglected and complex deformities, many of whom would be considered high-risk for COVID-19 associated morbidities.…”

“… 11 - 14 Additionally, these patients have been shown to experience higher rates of arthritis, 12 worse quality of life while waiting for surgery, 15 longer hospital length of stay (LOS), and more complications after arthroplasty. 13 , 14 , 16 The suspension of arthroplasty procedures, therefore, created a tremendous backlog of arthroplasty patients with neglected and complex deformities, many of whom would be considered high-risk for COVID-19 associated morbidities. 17 Furthermore, as the safety net hospital for the surrounding hospitals, there was an ethical responsibility of caring for all COVID-19 patients who were unable to obtain care elsewhere.…”

Outcomes of an Institutional Rapid Recovery Protocol for Total Joint Arthroplasty at a Safety Net Hospital

“… 14 , 15 Safety net hospitals are defined as those which “by mandate or mission deliver a large amount of care to uninsured and other vulnerable populations.” 16 Unlike other cohorts, patients at safety net county hospitals tend to be of lower socioeconomic status with higher rates of housing insecurities, language disparities, comorbidities, and substance abuse. 17 , 18 Patient cohorts in these safety net hospitals have also been shown to experience higher rates of arthritis, 19 worse quality of life while awaiting surgery, 20 longer hospital LOS, and more complications after TJA. 17 , 18 , 21 Although these disparities create a unique set of challenges, the implementation of a standardized, multidisciplinary RRP could be of notable value in this cohort.…”

“… 17 , 18 Patient cohorts in these safety net hospitals have also been shown to experience higher rates of arthritis, 19 worse quality of life while awaiting surgery, 20 longer hospital LOS, and more complications after TJA. 17 , 18 , 21 Although these disparities create a unique set of challenges, the implementation of a standardized, multidisciplinary RRP could be of notable value in this cohort.…”