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Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007–2014
  1. Melvin La1,
  2. Virginia Tangel2,
  3. Soham Gupta2,
  4. Tiffany Tedore1 and
  5. Robert S White1
  1. 1Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York City, New York, USA
  2. 2Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
  1. Correspondence to Dr Robert S White, Anesthesiology, NewYork Presbyterian Hospital-Weill Cornell Medical College, New York, NY 10065, USA; rsw33{at}


Background Total hip arthroplasty (THA) is one of the most widely performed surgical procedures in the USA. Safety net hospitals, defined as hospitals with a high proportion of cases billed to Medicaid or without insurance, deliver a significant portion of their care to vulnerable populations, but little is known about the effects of a hospital’s safety net burden and its role in healthcare disparities and outcomes following THA. We quantified safety net burden and examined its impact on in-hospital mortality, complications and length of stay (LOS) in patients who underwent THA.

Methods We analyzed 500 189 patient discharge records for inpatient primary THA using data from the Healthcare Cost and Utilization Project’s State Inpatient Databases for California, Florida, New York, Maryland and Kentucky from 2007 to 2014. We compared patient demographics, present-on-admission comorbidities and hospital characteristics by hospital safety net burden status. We estimated mixed-effect generalized linear models to assess hospital safety burden status’ effect on in-hospital mortality, patient complications and LOS.

Results Patients undergoing THA at a hospital with a high or medium safety net burden were 38% and 30% more likely, respectively, to die in-hospital compared with those in a low safety net burden hospital (high adjusted OR: 1.38, 95% CI 1.10 to 1.73; medium adjusted OR: 1.30, 95% CI 1.07 to 1.57). Compared with patients treated in hospitals with a low safety net burden, patients treated in high safety net hospitals were more likely to develop a postoperative complication (adjusted OR: 1.11, 95% CI 1.00 to 1.24) and require a longer LOS (adjusted IRR: 1.06, 95% CI 1.05, 1.07).

Conclusions Our study supports our hypothesis that patients who underwent THA at hospitals with higher safety net burden have poorer outcomes than patients at hospitals with lower safety net burden.

  • total hip arthroplasty
  • hospital safety net burden
  • administrative database research
  • outcomes research

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  • Contributors All authors contributed to, read, and approved this manuscript. Authors worked on the following aspects of the project: ML: planning, conception and design, interpretation of data and conduct. VT: planning, acquisition of data, analysis of data and interpretation of data. SG: planning, conception and design, interpretation of data, conduct and reporting. TT: planning, conception and design and interpretation of data. RSW: planning, conception and design, interpretation of data, conduct and reporting.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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