Closer and Wealthier, Not Healthier: Proximity and Socioeconomic Status Drive Ambulatory Surgery Center Selection...

Ambulatory surgery centers (ASCs) are increasingly used for total joint arthroplasty (TJA), offering lower costs and shorter stays than hospitals. However, access to ASC-based arthroplasty remains uneven, with socioeconomic and geographic disparities suspected to influence which patients receive outpatient care. This study evaluated how community-level socioeconomic status (SES) and travel distance affect the likelihood of undergoing TJA at an ASC versus a hospital.

A retrospective cohort analysis was conducted of 5,560 patients who underwent primary total hip or knee arthroplasty at a single academic center between 2018 and 2024. Of the cohort, 2,113 patients underwent surgery at the ASC and 3,447 at the hospital. Patient demographics, comorbidities, distressed communities index scores, and travel distance to the surgical facility were collected. A multivariable logistic regression was used to identify independent predictors of ASC utilization.

The ASC patients were significantly younger, traveled shorter distances, and lived in communities with lower socioeconomic distress. In adjusted models, increasing age (OR [odds ratio] = 0.96), greater travel distance (OR = 0.999), and higher distressed communities index scores (OR = 0.995) were associated with lower odds of ASC surgery. Black patients had significantly reduced ASC utilization compared with White patients (OR = 0.79). Higher comorbidity burden was unexpectedly associated with greater ASC use (OR = 1.34).

The ASC utilization for TJA is shaped by intersecting demographic, socioeconomic, and geographic factors. Patients from less distressed communities and those living closer to the facility are more likely to undergo ASC-based surgery, while older and Black patients remain less likely to receive care in these settings. Targeted efforts to expand ASC access and address structural barriers are needed to ensure equitable adoption of outpatient arthroplasty.