The effect of patient point of entry and Medicaid status on quality outcomes following total hip arthroplasty

Abstract

Aims Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. Methods The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. Results A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or ‘other’ race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. Conclusion After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78–84.

Social Determinants of Health Influence Access to Care and Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review

“…23 Furthermore, public health insurance patients carry higher odds of requiring acute medical care within 30 days after ACLR. 32 Studies investigating the impact race/ethnicity and insurance status have on postoperative complications have reported similar findings among orthopaedic [70][71][72][73][74] and spine 75,76 patients. These findings emphasize the disparity in access to care between patient populations experiencing social deprivation or social support as the result of their SDOH, which directly affect outcomes after ACLR.…”

Patients With Medicaid Insurance Undergoing Anterior Cruciate Ligament Reconstruction have Lower Postoperative International Knee Documentation Committee Scores and are Less Likely to Return to Sport Than Privately Insured Patients

“… 22 , 23 , 24 , 25 More specifically, recent investigations have demonstrated that in those undergoing total joint arthroplasty of the hip, knee, or shoulder, patients with Medicaid have greater resource use, greater complication rates, and poorer postoperative outcomes. 8 , 10 , 13 , 14 , 23 , 26 , 27 With the expansion of Medicaid through the Affordable Care Act in 2014, the investigation of these disparities in one of the most common orthopaedic sports medicine procedures performed, ACL reconstruction, is critical. 23 …”

“…[22][23][24][25] More specifically, recent investigations have demonstrated that in those undergoing total joint arthroplasty of the hip, knee, or shoulder, patients with Medicaid have greater resource use, greater complication rates, and poorer postoperative outcomes. 8,10,13,14,23,26,27 With the expansion of Medicaid through the Affordable Care Act in 2014, the investigation of these disparities in one of the most common orthopaedic sports medicine procedures performed, ACL reconstruction, is critical. 23 When assessing our primary outcome, despite similar preoperative IKDC scores (53.65 vs 53.95; P ¼ .978) between the 2 cohorts, we found significantly lower postoperative IKDC scores (P ¼ .005) at final follow-up in patients with Medicaid insurance compared with those with private insurance (74.68 vs 90.45, respectively; P ¼ .005).…”

“…For instance, patients insured through Medicaid undergoing total joint arthroplasty of the hip or knee have been reported to have greater resource use and greater complications rates. 8 , 9 , 10 , 11 , 12 For those undergoing shoulder arthroplasty procedures, patients insured through Medicaid demonstrated greater complication rates, lower follow-up rates, and inferior postoperative PROs. 13 , 14 , 15 Similarly, multiple studies reported inferior PROs in patients insured through Medicaid who underwent a variety of foot and ankle procedures.…”

30-day to 10-year mortality rates following total hip arthroplasty: a meta-analysis of the last decade (2011–2021)

“…Socioeconomic disadvantage has been associated with higher mortality rates after THA. [20][21][22] Rhee et al 23 reported increased risk for mortality with blood transfusions (OR 2.6; 95% CI, 1.3-5.3), myocardial infarction (OR 7.9; 95% CI, 2.6-24. Obesity has been associated with mixed results in regard to mortality after THA.…”