The Removal of Total Hip Arthroplasty From the Inpatient-Only List has Improved Patient Selection and Expanded
Niall H Cochrane1, Billy I Kim1, Thorsten M Seyler1
1Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.
Insights
Total hip arthroplasty (THA) is now outpatient surgery after removal from the Inpatient-Only (IPO) list. Post-removal, patients were older but had similar 30-day outcomes and better preoperative optimization.
Area of Science:
- Orthopedic surgery
- Health services research
- Patient outcomes
Background:
- Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the Inpatient-Only (IPO) list on January 1, 2020.
- This policy change allowed THA to be performed as an outpatient procedure.
Purpose of the Study:
- To evaluate patient demographics and comorbidities for outpatient THA before and after IPO removal.
- To assess preoperative optimization efforts for modifiable risk factors.
- To compare 30-day outcomes (readmissions, reoperations) for outpatient THA before and after IPO removal.
Main Methods:
- A national database of 17,063 outpatient THAs was analyzed, stratified by surgery date (pre-IPO: 2015-2019; post-IPO: 2020).
- Demographics, comorbidities, and 30-day outcomes were compared using univariable and multivariable analyses.
- Preoperative optimization thresholds for albumin, creatinine, hematocrit, smoking history, and BMI were established and compared between cohorts.
Main Results:
- Patients undergoing outpatient THA post-IPO removal were older (mean age 65 vs. 62 years) and had higher American Society of Anesthesiologists scores (3 and 4).
- No significant differences were observed in 30-day readmissions (P=.57) or reoperations (P=1.00).
- A lower percentage of patients fell outside the albumin threshold (P<.01) post-IPO removal, with trends towards lower percentages for hematocrit and smoking status.
Conclusions:
- Removal of THA from the IPO list has expanded patient selection for outpatient arthroplasty.
- Preoperative optimization remains critical for minimizing postoperative complications.
- The study demonstrates that 30-day outcomes have not worsened following the removal of THA from the IPO list.
Background:
On January 1, 2020, the Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the Inpatient-Only (IPO) list. This study evaluated patient demographics and comorbidities, preoperative optimization efforts, and 30-day outcomes of patients undergoing outpatient THA before and after IPO removal. The authors hypothesized that patients undergoing THA post-IPO removal would have improved optimization of modifiable risk factors and equivalent 30-day outcomes.
Methods:
There were 17,063 outpatient THAs in a national database stratified by surgery performed before (2015 to 2019: 5,239 patients) and after IPO (2020: 11,824 patients) removal. Demographics, comorbidities, and 30-day outcomes were compared with univariable and multivariable analyses. Preoperative optimization thresholds were established for the following modifiable risk factors: albumin, creatinine, hematocrit, smoking history, and body mass index. The percentage of patients who fell outside the thresholds in each cohort were compared.
Results:
Patients undergoing outpatient THA post-IPO removal were significantly older; mean age 65 years (range, 18 to 92) versus 62 (range, 18 to 90) years (P < .01), with a higher percentage of American Society of Anesthesiologists scores 3 and 4 (P < .01). There was no difference in 30-day readmissions (P = .57) or reoperations (P = 1.00). A significantly lower percentage of patients fell outside the established threshold for albumin (P < .01) post-IPO removal, and trended towards lower percentages for hematocrit and smoking status.
Conclusion:
The removal of THA from the IPO list expanded patient selection for outpatient arthroplasty. Preoperative optimization is critical to minimize postoperative complications, and the current study demonstrates that 30-day outcomes have not worsened post-IPO removal.
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