Date of Award

2024

Embargo Period

5-1-2026

Document Type

Dissertation

Degree Name

Doctor of Health Administration

College

College of Health Professions

First Advisor

Daniel Brinton

Second Advisor

Brian Olkowski

Third Advisor

Zahi Jurdi

Abstract

Background: Osteoarthritis in the hip joint leads to worn or damaged cartilage, resulting in bones scraping against each other. This scraping creates rough surfaces, causing significant pain and limiting mobility in daily activities. THA becomes necessary when other less invasive options fail to alleviate symptoms such as pain, stiffness, swelling, and reduced range of motion. Due to high out-of-pocket costs and the rapid spread of COVID-19, CMS took a substantial stride in healthcare policy by introducing the CMS-1736-FC ruling in December 2020. This ruling, effective from January 2021, facilitated the reclassification of eleven procedures, including Total Hip Arthroplasties (THAs), from inpatient-only to outpatient status.

Methods: The study will be a propensity-matched retrospective quantitative cohort study with three objectives: compare total costs and readmission rates between OP and IP THA, explore rehabilitation impact and costs post-IP vs. OP THA, and address potential medical complexity differences using Charlson Comorbidity Score and The Elixhauser Comorbidity Index. The inclusion criteria for this study were set for adults 18 years old and older who had an elective THA. In contrast, the exclusion criteria were set for patients who underwent an emergent THA, had metastatic cancer to the hip joint, or underwent a revision of THA.

Results: The adjusted model for THA total costs concludes that surgery undertaken in the IP setting cost, on average, $8,135 (95% CI: $7,823-8,457; p < 0.0001) more than one undertaken in the OP setting. The adjusted mean values of IP vs. OP THA Rehab Costs (90 Days Post-THA) indicate OP rehabilitation, on average, costs $251 more than IP (95% CI: $247-254; p < 0.0001). The adjusted mean Rehabilitation Days (90 Days Post-THA) indicate an additional 2.7 days of rehabilitation post-IP THA vs. OP (95% CI 2.3-3.1 days; p < 0.0001). Adjusted All-Cause Readmission (90 Days Post-THA) Outpatient vs. Inpatient variable had a Hazard Ratio of 2.211, which indicates patients undergoing IP THA were 2.2 times more prone to experience readmission within 90 days post-THA than those who underwent OP THA. The unadjusted model concludes that IP readmission rates (90 days post-THA) were 2.6 times higher than OP (p < 0.0001). All models were adjusted for Age, Region, and Charlson Comorbidity Score.

Conclusion: THA procedures conducted in an OP setting demonstrated lower costs than those performed in a traditional IP setting. However, upon closer examination of rehabilitation costs 90 days post-THA, it became apparent that OP rehabilitation costs exceeded those associated with IP care. This finding may be attributed to the prevalence of episode-based payment systems, commonly known as bundled payments, exemplified by CMS's Comprehensive Care for Joint Replacement (CJR) model for Medicare beneficiaries. Payers frequently provide bundled payments for inpatient THA, encompassing post-THA IP rehabilitation services reimbursement. Subsequently, the data revealed that OP THA results in a statistically significant decrease in rehabilitation duration compared to the traditional IP method. Lastly, OP THA demonstrated lower observed readmission rates than traditional IP THA.

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