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. 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.