The Centers for Medicare and Medicaid Services has solicited comments regarding the removal of total hip arthroplasty (THA) from its inpatient-only list. The goal of this study is to develop and internally validate a risk stratification nomogram to aid in the identification of optimal inpatient candidates in this patient population.
The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify all patients >65 years of age who underwent primary THA between 2006 and 2015. Inpatient stay was the primary outcome measure, as defined by stay >2 days in length. The impact of numerous demographic, comorbid, and perioperative variables was assessed through a multivariable logistic regression analysis to construct a predictive nomogram.
In total, 30,587 inpatient THAs and 17,024 outpatient THAs were analyzed. Heart failure (odds ratio [OR] 2.11, P = .001), simultaneous bilateral THA (OR 2.47, P < .0001), age >80 years (OR 2.91, P < .0001), female gender (OR 1.90, P < .0001), and dependent functional status (OR 1.89, P < .0001) were the most influential determinants of inpatient status. The final prediction algorithm showed good accuracy, excellent calibration, and internal validation (bias-corrected concordance index of 0.69).
Our model enabled accurate and simple identification of the best candidates for inpatient admission after THA in Medicare-aged patients. Given the increasing feasibility of outpatient THA coupled with the likelihood of THA being removed from the Centers for Medicare and Medicaid Services inpatient-only list, this model provides a framework to guide discussion and decision-making for stakeholders.