Disparities in Access to Outpatient Surgery Related to Removal of Procedures From Medicare's Inpatient-only List

Abstract

Objective: To assess the shift from inpatient to outpatient surgical care related to changes to the inpatient-only list in 2020 and 2021 compared with 2019.

Background: The extent to which procedures shift from the inpatient to outpatient setting after removal from Medicare's inpatient-only (IPO) list is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the coronavirus disease 2019 (COVID-19) pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the IPO list during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to the outpatient setting.

Methods: We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient versus inpatient procedural volume in 2020 and 2021 compared with 2019 using a multivariable conditional fixed-effect Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures.

Results: In 2020 and 2021, compared with 2019 respectively, there was a 5.3% (95% CI: 1.4% to 9.5%) and 41.3% (95% CI: 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the IPO list in 2020 [increase in outpatient surgical utilization of 589.3% (95% CI: 524.9% to 660.3%)]. The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI: 241.2% and 303.7%) for White patients and 29.5% (95% CI: 24.4% and 34.9%) for Black patients compared with 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared with 2019.

Conclusions: There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the IPO list during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.

Keywords: elective surgery; hip replacement; inpatient/outpatient surgical care; racial and ethnic disparities.