Disparities in Outpatient and Short-Stay Arthroplasty Surgery: a Critical Review and Proposed Equity-Centered Framework

Abstract

Purpose of Review

Over the past decade, outpatient and short-stay total joint arthroplasty (TJA) has transitioned from exception to expectation, driven by enhanced recovery protocols, regulatory changes, and the COVID-19 pandemic. This review synthesizes evidence from 2015 to 2025 regarding inequities in this transition, clarifies key definitions and methodological challenges, and examines the contributing factors and controversies surrounding equitable access to ambulatory surgery.

Recent Findings

Evidence indicates a widening gap in access and outcomes based on race, ethnicity, and gender. Black and Hispanic patients remain significantly less likely than White patients to undergo outpatient TJA, even when controlling for clinical comorbidities. Recent data also suggests that residence in socioeconomically disadvantaged neighborhoods is associated with longer lengths of stay and higher early healthcare utilization. Furthermore, sex-based differences have emerged in postoperative pain management, with women demonstrating higher rates of opioid exposure and persistence. While younger, healthier, and privately insured patients have disproportionately benefited from outpatient pathways, those with public insurance or higher comorbidity burdens face persistent structural barriers to candidacy and safe discharge.

Summary

Achieving equitable outpatient TJA requires a shift from exclusionary risk-screening to an equity-centered framework. This proposed model spans inclusive candidacy, optimization through prehabilitation, care navigation, and the use of site-of-service metrics. Ultimately, mitigating these disparities will require coordinated, multilevel action across policy reform, clinical practice innovation, and community engagement to ensure that the benefits of surgical innovation are accessible to all patient populations.

Introduction

The landscape of total joint arthroplasty (TJA) has undergone a profound transformation over the past two decades. Once considered exclusively inpatient procedures, hip and knee replacements (THA and TKA) are now increasingly performed in outpatient and same-day settings. This shift reflects advances in anesthesia, multimodal analgesia, and enhanced recovery pathways, alongside broader policy pressures to improve value and contain costs. For many patients, outpatient TJA offers shorter lengths of stay, fewer opportunities for hospital-acquired complications, and an earlier return to function [1].

Despite the advances that have enabled outpatient TJA, its benefits have not been distributed equitably. Disparities linked to demographics, socioeconomic position, insurance coverage, social support, and geography have produced uneven adoption of ambulatory pathways. Patients with greater resources, private insurance, and robust home supports are more likely to access outpatient care, whereas historically marginalized and clinically complex populations often face structural barriers to eligibility, optimization, and safe discharge planning [2]. These inequities risk widening existing gaps in musculoskeletal health outcomes, undermining the promise of outpatient surgery as a universal standard of care.

As outpatient TJA becomes the norm, evaluative metrics must extend beyond safety and cost-effectiveness to include equity. Emerging literature suggests that, in the absence of deliberate safeguards, outpatient expansion may amplify rather than mitigate systemic inequities [3, 4]. This review synthesizes evidence on disparities in outpatient and short-stay arthroplasty, examines mechanisms driving these gaps, and outlines potential solutions spanning perioperative innovation, care-navigation supports, and policy-level interventions.

Methods

We searched PubMed, Embase, Web of Science, and Cochrane databases for articles published between January 2015 and September 2025. The search combined terms related to arthroplasty (THA and TKA), outpatient surgery, short-stay or same-day discharge, and disparities. The initial search yielded several hundred abstracts, of which studies were screened at the title and abstract level for relevance. Studies were included if they reported on utilization patterns, patient outcomes, or system-level factors influencing disparities. Randomized controlled trials, systematic reviews, meta-analyses, and large national database studies were prioritized. Observational studies and policy analyses were also included to provide novel insights into equity-related issues. Studies focused solely on surgical techniques or perioperative protocols without addressing disparities were excluded. This review was designed as a critical narrative synthesis to highlight key themes, controversies, and gaps in the current literature, rather than a formal systematic review or meta-analysis.

Definitions and Methodological Caveats

Interpretation of current data requires attention to definitions. Outpatient status in claims databases is an administrative designation that can include patients staying at least one night, whereas clinical same‑day discharge refers to leaving the facility on the day of surgery. Studies that conflate these categories may obscure true associations between pathways and outcomes. Additionally, many large datasets lack granular social data (caregiver availability, housing characteristics, transportation reliability, broadband access, etc.). which may confound observed associations. Furthermore, selection bias is common, as early ambulatory surgery center (ACS) experiences often originated from high‑performing programs with robust navigation that may not generalize to resource‑constrained settings.

Evolution of Outpatient and Short-Stay Arthroplasty

The evolution of outpatient arthroplasty reflects major advances in surgical and anesthetic techniques, enhanced pain control, and optimized perioperative care pathways. Until the mid-2010s, THA and TKA procedures routinely required several days of inpatient hospitalization. By the late 2010s, however, the adoption of multimodal analgesia, regional anesthesia, and enhanced recovery protocols enabled safe same-day discharges in selected populations [5].

Policy changes further accelerated this shift, notably the Centers for Medicare & Medicaid Services (CMS) removal of TKA and THA from the inpatient-only list in 2018 and 2020 respectively. The COVID-19 pandemic acted as a powerful catalyst for this transition. Hospital systems faced significant bed shortages and infection-control challenges, creating strong incentives to shift TJA into ASCs and short-stay models. Surgeons adapted by streamlining protocols and leveraging telemedicine to limit face-to-face interactions and decrease the risk of viral exposure. Several studies documented a marked increase in outpatient TJA volumes between 2020 and 2022, with ASCs playing a growing role in maintaining surgical throughput [4, 6, 7]. Concurrently, the pandemic reshaped patient preferences, as many sought to avoid overnight stays to reduce exposure to COVID-19 [6]. By the mid-2020s, clinical innovation and regulatory support firmly established outpatient arthroplasty as a dominant care model in the United States.

Disparities in Utilization

Disparities in the utilization of outpatient arthroplasty have been documented extensively across multiple large-scale datasets and health systems [2–4, 8]. Racial and ethnic inequities are among the most consistently reported findings. Black and Hispanic patients undergo outpatient TJA at significantly lower rates compared with White counterparts, even after accounting for age, comorbidities, and insurance coverage [2]. These gaps persist despite evidence that minority patients derive equal or greater benefit in terms of pain relief and functional recovery when access is secured [9, 10].

Structural barriers, including geographic proximity to high-volume centers and referral biases, play a central role [11]. In some regions, outpatient centers are disproportionately located in affluent, predominantly White neighborhoods [12]. Socioeconomic status creates additional barriers to access. Patients with private insurance are consistently overrepresented, while those covered by Medicaid are less likely to undergo surgery in ambulatory settings [11]. Financial disincentives in reimbursement structures may partially explain this, as some facilities are reluctant to accept lower-paying public payers [13]. Additionally, patients from lower-income neighborhoods often face logistical barriers, such as transportation challenges or lack of caregiver availability, which can influence surgeon recommendations [3].

Disparities in Outcomes

Disparities in outcomes mirror those observed in utilization, raising concerns that structural inequities extend to post-TJA recovery. Evidence suggests that minority and socioeconomically disadvantaged patients experience slightly higher rates of readmissions and unplanned emergency department visits after outpatient TJA [4, 14]. These differences appear to be mediated by disparities in social support and postoperative monitoring rather than by inherent physiological risk.

While functional improvements are broadly consistent, differences emerge in patient-reported satisfaction [10]. Minority patients are more likely to report feeling inadequately informed, and lower health literacy may contribute to unmet expectations [3]. Cultural discordance between patients and providers can also undermine trust and shared decision-making [4]. Conversely. interventions emphasizing language-concordant communication and structured education have been shown to reduce these gaps [3].

Gender‑based differences are also noteworthy. While men often receive higher perioperative opioid doses, women are more likely to demonstrate postoperative opioid persistence [15, 16]. These patterns underscore the need for sex-sensitive counseling and standardized pain stewardship within outpatient pathways.

Contributing Factors

A complex interplay of clinical, structural, and systemic forces contributes to disparities in outpatient arthroplasty. Patient selection protocols, while intended to promote safety, frequently serve as the first barrier [17]. Criteria excluding patients for advanced age, obesity, or cardiometabolic disease may disproportionately affect disadvantaged populations where these conditions are more prevalent due to longstanding inequities in healthcare access.

At the facility level, ASCs are often located in affluent areas to maximize profitability rather than address population needs [18]. Geographic distance, transportation limitations, and inflexible work schedules further compound access barriers [19]. Provider-level dynamics, including implicit biases and differential perceptions of risk, also influence candidacy. Minority patients may be less likely to be recommended for outpatient procedures even when clinically eligible [20]. Furthermore, policy-level incentives like bundled payments may inadvertently discourage providers from treating patients with complex medical or social needs, who are perceived as financially “risky”. Without risk adjustment for social disadvantage, such policies risk further marginalizing vulnerable populations.

Controversies and Hypotheses

The shift toward outpatient care has generated significant debate regarding the balance of safety and equity. A central controversy involves patient selection criteria. Proponents argue for strict eligibility thresholds to ensure the safety of same-day discharge [5, 21]. Critics, on the other hand, contend that such criteria are overly restrictive and exclude patients who could benefit if given adequate support [17, 21]. This raises the fundamental question of whether the current approach prioritizes risk avoidance over equitable access to innovative care models.

There is also increasing recognition that postoperative recovery may depend more heavily on social determinants of health than clinical factors [22]. Patients with strong caregiver networks, reliable transportation, and safe home environments recover more smoothly than those without such supports, regardless of their medical risk profile [23]. This observation has led to the hypothesis that integrating social risk assessment into surgical planning is as critical as traditional medical risk stratification [24, 25].

Finally, policy reform is another topic of ongoing debate. While value-based reimbursement models encourage efficiency and shorter hospital stays, they also create unintended incentives that discourage the inclusion of higher-risk patients, many of whom belong to vulnerable populations [26]. This concern has further reinforced calls for social risk adjustment to prevent the exclusion of higher-risk patients, although the optimal design and implementation of such mechanisms remain contested [27].

Emerging Solutions and Strategic Frameworks

Disparities in arthroplasty outcomes are not permanent. Evidence suggests that when health systems implement standardized pathways alongside equitable resource allocation, significant gaps in utilization and outcomes begin to narrow [14]. The following strategies represent high-leverage opportunities for clinical and systemic reform:

• Enhanced Recovery Protocols (ERPs): ERPs serve as a cornerstone for standardizing perioperative care. By utilizing multimodal analgesia, early mobilization, and structured patient education, ERPs reduce the clinical “noise” created by inconsistent practices. These protocols have been demonstrated to broaden eligibility for same-day discharge among populations previously deemed high-risk due to medical or social complexity [28].

• Reimbursement Reform and Social Risk Adjustment: Current value-based payment models often penalize providers for treating patients with complex social needs. Incorporating social risk adjustment into these models is essential to mitigate the financial disincentives associated with caring for marginalized populations. Pilot programs indicate that when reimbursement reflects the added navigation and coordination required for disadvantaged patients, access to outpatient TJA expands more equitably [10].

• Technological and Community-Based Integration: Telehealth and remote patient monitoring minimize the geographic and transportation burdens of traditional follow-up. Furthermore, partnerships with community organizations, including facilitating rideshare vouchers and employing language-concordant care navigators, directly address the logistical barriers that frequently preclude same-day discharge for lower-income patients [29].

• Equity-Focused Performance Metrics: Transparency is a prerequisite for progress. By embedding stratified data (e.g., race, ethnicity, sex, and zip code) into hospital-wide quality reporting, health systems can identify hidden inequities in same-day discharge rates and readmission patterns [30]. These metrics move equity from an abstract goal to a tangible performance indicator.

Program Design: an Equity-Centered Framework (Fig. 1)

Fig. 1.

The equity-centered framework for outpatient TJA

Transitioning toward equity-forward outpatient TJA requires a paradigm shift from exclusionary screening to inclusive optimization. Rather than utilizing risk-screening models to disqualify complex patients, a two-stage candidacy process should be adopted (Fig. 1).

1. Comprehensive Clinical Safety Assessment: A review of anesthetic risk, frailty, and pertinent comorbidities.

2. Structured Social Appraisal: A proactive assessment of social determinants of health that triggers immediate resource deployment rather than cancellation of the procedure.

Optimization as Prehabilitation

Rather than disqualifying patients solely on the basis of modifiable risk factors, optimization should be embedded into prehabilitation programs. For example, targeted programs for smoking cessation and nutritional support build patient trust and expand the pool of candidates eligible for ambulatory pathways.

Caregiver Engagement and Support

Caregiver availability is a frequent “hard stop” for outpatient candidacy. To promote equity, systems must provide tangible supports, including culturally and linguistically concordant education and transportation vouchers. These interventions transform home-based recovery from a daunting hurdle into a manageable process. On the day of surgery, the use of standardized regional anesthesia and teach-back discharge education ensures that both the patient and their support system are equipped for the first 48 h of recovery.

Post-Discharge Vigilance

The transition to home must be supported by a structured safety net. A “virtual rounding” contact within 24–48 h allows for the early identification of common postoperative issues like pain or nausea, preventing unnecessary emergency department utilization. Furthermore, system-level dashboards must track opioid prescribing patterns across demographic subgroups to ensure that pain management remains both effective and equitable, reducing the risk of long-term dependence in vulnerable populations.

Ultimately, an equity-forward pathway is defined by its resilience and its ability to adapt to the unique needs of the individual patient. By embedding optimization, caregiver support, and data-driven vigilance into the core of the outpatient model, the orthopaedic community can ensure that surgical innovation serves all patients fairly.

Future Directions

Future directions in addressing disparities in outpatient and short-stay arthroplasty require coordinated action at multiple levels: policy, clinical practice, research, and community engagement. On the policy front, a pressing need exists to reform reimbursement models so that they incorporate social risk adjustment. Without this, hospitals and surgeons may remain hesitant to extend outpatient pathways to disadvantaged groups. In addition, targeted funding to expand ASCs in underserved urban and rural communities could address geographic inequities.

Clinically, embedding standardized care protocols that integrate both medical and social risk factors into patient selection processes will be essential. Future models may incorporate not only comorbidity scores but also validated measures of home support, health literacy, and neighborhood disadvantage. Programs that enhance perioperative patient education, particularly through culturally tailored and language-concordant materials, should be prioritized to improve both utilization and outcomes in diverse populations.

From a research perspective, significant gaps remain. Few randomized controlled trials stratify outcomes by race, socioeconomic status, or insurance type, limiting the ability to draw definitive conclusions about disparities. Future studies are needed to oversample historically underrepresented groups to generate evidence that can directly inform equity-focused interventions. Studies should also clearly distinguish same-day surgery from the broader category of outpatient arthroplasty. Implementation science approaches should also be leveraged to identify which strategies most effectively translate equity goals into routine practice across varied health system contexts.

Finally, community engagement will be critical. Health systems should partner with local organizations, community health workers, and patient advocates to design outpatient arthroplasty pathways that reflect the lived realities of diverse patient populations. Integrating telehealth and community-based follow-up services into these pathways could ensure that patients who face logistical and socioeconomic challenges receive the support needed for safe recovery.

Conclusion

Short-stay arthroplasty represents a paradigm shift in orthopedic delivery, offering optimized perioperative efficiency, safety, and high-value patient-centered outcomes. Yet, the persistent disparities in utilization and outcomes demonstrate that technological and clinical innovation alone is insufficient to guarantee equity. Racial and ethnic minorities, low-income patients, and those residing in rural or underserved communities remain disproportionately excluded from short-stay pathways. Furthermore, when these populations do access ambulatory care, they often face heightened risks of adverse outcomes.

These inequities are not inherent biological traits but arise from modifiable systemic and structural factors, including mismatched facility distribution, unconscious provider practices, and misaligned policy incentives. This review highlights that disparities in outpatient arthroplasty are neither inevitable nor insurmountable. Emerging evidence suggests that when health systems implement standardized enhanced recovery protocols, risk-adjusted payment models, and robust socio-clinical postoperative support, utilization gaps narrow considerably. The controversies surrounding patient selection, the mechanistic role of social determinants, and the design of policy incentives underscore the imperative for deliberate, equity-focused strategies.

Moving forward, clinical excellence must be redefined to embed equity as a central metric of quality in arthroplasty, rather than a secondary consideration. In summary, the long-term viability of outpatient and short-stay arthroplasty depends on ensuring that its benefits are equitably distributed across the population spectrum. Achieving this goal will require coordinated, multilevel interventions ranging from reimbursement reforms and clinical innovations to community partnerships and research agendas explicitly designed for disparity reduction. Only by addressing these structural issues head-on can the field of arthroplasty realize its full potential as a driver of both clinical excellence and social equity.

Author Contributions

MH conceived and designed the study, performed the investigation, analyzed and interpreted the data, prepared the figures, and wrote the manuscript.

Funding

None.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Human and Animal Rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

Competing interests

The authors declare no competing interests.