Elevated Length of Stay and Cost of Orthopedic Hospitalization are Associated with Urban Setting, Non-Trauma Diagnosis, and Medicare Enrollment

Angel G A Prempeh,1 Olorunferanmi Oni,2 Allison Tenfelde1 1College of Human Medicine, Michigan State University, East Lansing, Michigan, USA; 2College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USACorrespondence: Angel G A Prempeh, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA, Email [email protected]: Disparities in orthopedic care delivery across hospital settings and payer types may significantly correlate with length of stay (LOS), cost burden, and care efficiency. This study quantifies the associations between geographic location, case acuity, insurance status and resource utilization in Michigan.Methods: We conducted a retrospective cohort study using 2018– 2020 discharge records from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for Michigan. Orthopedic-related hospitalizations were identified and stratified by hospital location (urban vs rural), injury mechanism (trauma vs non-trauma), and primary payer (Medicare, Medicaid, private, other, uninsured). Outcomes included LOS, per-discharge cost, aggregate hospital-level expenditures, and population-adjusted discharge rates. Statistical comparisons were performed using two-sample t-tests and ANOVA. Independent associations were evaluated via mixed-effects regression models with hospital-level random intercepts.Results: Among 334,756 orthopedic discharges, urban facilities recorded longer average LOS (4.57 vs 4.09 days; P< 0.001) and higher mean aggregate costs per hospital ($8.70M vs $1.74M; P< 0.001) than rural counterparts. Non-traumatic cases were associated with greater per-stay costs ($19,645 vs $16,630; P< 0.001). Uninsured patients experienced the longest LOS (4.70 days), followed by Medicare (4.35 days), Medicaid (3.89 days), private (3.72 days), and other (3.06 days; all P< 0.001). Medicare accounted for the largest hospital-level expenditure ($3.28M mean; P< 0.001). Mixed-effects models confirmed urban setting, non-trauma diagnosis, and Medicare enrollment as independent factors associated with elevated LOS and cost (P< 0.001).Conclusion: Orthopedic care patterns demonstrate distinct variations linked to structural, clinical, and financial factors. These findings highlight disparities that may inform future discussions on reimbursement policies and rural capacity planning.Plain Language Summary: Why did we do this study?A broken bone or worn-out joint should not mean a longer hospital stay or a bigger bill just because of where you live or your insurance. Yet, these differences are real and they affect patients every day. We needed solid data to reveal exactly what is happening, so policymakers can make smart, evidence-based changes to improve fairness and cut waste. We use Michigan statewide data as a case study.What did we do?We examined 334,756 real hospital records for orthopedic care in Michigan from 2018 to 2020. We sorted them by: Location: city (urban) vs rural hospitals, Injury type: sudden (trauma) or long-term (non-trauma, like arthritis) and Insurance: Medicare, Medicaid, private, other, or none.We tracked stay length, cost per patient, total spending per hospital, and admission rates.What did we find?City hospitals kept patients longer (4.6 vs 4.1 days) and spent five times more per hospital ($8.7 million vs $1.7 million). Non trauma cases cost more per stay than traumatic ones. Uninsured patients stayed longest (4.7 days); Medicare drove the biggest overall bills. Rural areas admitted more people per resident, likely due to fewer local clinics.What does this mean?Your address and insurance card can shape your orthopedic care. City hospitals manage tougher cases; rural ones stretch limited resources. With this data in hand, leaders can now fix insurance rules and strengthen rural clinics making healing faster, cheaper, and fairer for all Michiganders.Keywords: orthopedic, urban-rural, hospital costs, length of stay, trauma status, reimbursement, resource allocation