Related Experiment Video
Updated: Jul 30, 2025
The Transition to an Anterior-Based Muscle Sparing Approach Improves Early Postoperative Function but is Associated with a Learning Curve
Published on: September 7, 2022
Medicaid Patients Undergo Total Joint Arthroplasty at Lower-Volume Hospitals by Lower-Volume Surgeons and Have Poorer
Anna Cohen-Rosenblum1, Mary K Richardson2, Kevin C Liu2
1Department of Orthopaedic Surgery, Louisiana State University, New Orleans, Louisiana.
Background:
Medicaid insurance coverage among patients undergoing total hip arthroplasty (THA) or those undergoing total knee arthroplasty (TKA) has been associated with worse postoperative outcomes compared with patients without Medicaid. Surgeons and hospitals with lower annual total joint arthroplasty (TJA) volume have also been associated with worse outcomes. This study sought to characterize the associations between Medicaid insurance status, surgeon case volume, and hospital case volume and to assess the rates of postoperative complications compared with other payer types.
Methods:
The Premier Healthcare Database was queried for all adult patients who underwent primary TJA from 2016 to 2019. Patients were divided on the basis of their insurance status: Medicaid compared with non-Medicaid. The distribution of annual hospital and surgeon case volume was assessed for each cohort. Multivariable analyses were performed accounting for patient demographic characteristics, comorbidities, surgeon volume, and hospital volume to assess the 90-day risk of postoperative complications by insurance status.
Results:
Overall, 986,230 patients who underwent TJA were identified. Of these, 44,370 (4.5%) had Medicaid. Of the patients undergoing TJA, 46.4% of those with Medicaid were treated by surgeons performing ≤100 TJA cases annually compared with 34.3% of those without Medicaid. Furthermore, a higher percentage of patients with Medicaid underwent TJA at lower-volume hospitals performing ≤500 cases annually, 50.8% compared with 35.5% for patients without Medicaid. After accounting for differences among the 2 cohorts, patients with Medicaid remained at increased risk for postoperative deep vein thrombosis (adjusted odds ratio [OR], 1.16; p = 0.031), pulmonary embolism (adjusted OR, 1.39; p < 0.001), periprosthetic joint infection (adjusted OR, 1.35; p < 0.001), and 90-day readmission (adjusted OR, 1.25; p < 0.001).
Conclusions:
Patients with Medicaid were more likely to undergo TJA performed by lower-volume surgeons at lower-volume hospitals and had higher rates of postoperative complications compared with patients without Medicaid. Future research should assess socioeconomic status, insurance, and postoperative outcomes in this vulnerable patient population seeking arthroplasty care.
Level Of Evidence:
Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Insights
Medicaid patients undergoing total joint arthroplasty (TJA) are more likely to be treated by lower-volume surgeons and hospitals, leading to increased risks of complications like deep vein thrombosis, pulmonary embolism, infection, and readmission.
Area of Science:
- Orthopedic Surgery
- Health Services Research
- Public Health
Background:
- Medicaid coverage is linked to poorer outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA).
- Lower surgeon and hospital volume in total joint arthroplasty (TJA) is also associated with adverse outcomes.
Purpose of the Study:
- To investigate the relationship between Medicaid insurance status, surgeon case volume, and hospital case volume.
- To evaluate postoperative complication rates in TJA patients based on insurance type and provider volume.
Main Methods:
- Analysis of the Premier Healthcare Database for adult primary TJA patients (2016-2019).
- Stratification of patients by insurance status (Medicaid vs. non-Medicaid).
- Multivariable analyses adjusting for demographics, comorbidities, and provider volume to assess 90-day complication risks.
Main Results:
- 4.5% of 986,230 TJA patients had Medicaid.
- Medicaid patients were more frequently treated by low-volume surgeons (≤100 cases/year) and at low-volume hospitals (≤500 cases/year).
- Medicaid patients faced higher adjusted risks for deep vein thrombosis, pulmonary embolism, periprosthetic joint infection, and 90-day readmission.
Conclusions:
- Medicaid patients undergoing TJA are disproportionately treated by lower-volume providers, correlating with increased postoperative complications.
- Further research is needed to explore socioeconomic factors, insurance, and outcomes in this patient group.
Related Concept Videos
01:23Peripheral Artery Disease V: Postoperative Nursing Management
01:27Peripheral Artery Disease III: Interprofessional Care