Rural and Urban Hospitals Demonstrate Different Patterns of Declining Inpatient Arthroplasty Volume, 2013-2023

Background Total joint arthroplasty has shifted rapidly from inpatient to outpatient settings. We evaluated whether inpatient Medicare arthroplasty volume changed differently across rural and urban hospitals from 2013 to 2023. Methods Medicare Inpatient Hospitals—by Provider and Service files were analyzed. Hospitals with reportable Medicare Severity Diagnosis-Related Group 469/470 volume were classified as urban (Rural-Urban Commuting Area 1-3) or rural (Rural-Urban Commuting Area 4-10). A two-way fixed-effects model with hospital and year fixed effects assessed rural-urban differences in volume change using 2013 as reference. Persistence of reportable inpatient volume was evaluated among hospitals observed in 2013. Results The cohort included 25,002 hospital-year observations across 2911 hospitals. The mean volume declined from 203 to 59 cases at urban hospitals and from 84 to 37 at rural hospitals between 2013 and 2023. Rural hospitals had greater relative declines before 2020, but the association reversed thereafter; rural × year difference-in-differences estimates were +63.4 cases in 2020, +104.2 in 2021, +118.3 in 2022, and +121.0 in 2023 (all P < .001), indicating smaller declines among rural hospitals remaining observable. However, by 2023, 73.3% of rural vs 46.4% of urban hospitals observed in 2013 were no longer reportable; rural status remained associated with loss after adjustment for baseline volume (odds ratio, 1.55; 95% confidence intervals, 1.24-1.93; P < .001). Conclusions Inpatient arthroplasty declined substantially in both settings. Urban hospitals remaining observable experienced larger post-2020 volume declines, whereas rural hospitals were more likely to disappear from the reportable inpatient dataset. These patterns suggest different geographic manifestations of the national transition away from inpatient arthroplasty.