Social deprivation increases risks of death after heart surgery

Posted on Friday 3rd April 2009

A major study of more than 40,000 patients has shown that social deprivation significantly reduces patients’ chances of survival after heart surgery.

Research from the University of Birmingham and University Hospitals Birmingham NHS Foundation Trust has shown that patients from more socially deprived backgrounds had poorer survival rates after cardiac surgery both immediately after the operation (in hospital) and over five years of follow up.

These findings raise concerns that patients from deprived areas are not receiving the full benefits from proven surgical procedures.

This large scale research project involved the Birmingham and North West of England Cardiac Surgical Centres and the Quality & Outcomes Research Unit (QuORU) led by University Hospital Birmingham.

The paper, which is published today (Friday) in the British Medical Journal, looked at 44,902 patients (average age of 65) from the West Midlands and North West England, who received heart surgery at 5 different hospitals, between 1997 and 2007. This included data for a wide range of procedures including coronary bypass grafts and valve replacements. Deprivation for each patient was calculated using a scale compiled for the 2001 census.

Domenico Pagano who led the team of investigators from University Hospital Birmingham said: “This research suggests that the benefits of cardiac surgery are less in patients from deprived background. The challenge is to identify the factors that determine this gap and to address them

By conducting an extremely large analysis we are able to get a real sense of the factors which impact upon survival rates after cardiac surgery.

By looking at a large number of patients we have results that highlight national trends.

The success rates of common surgeries like coronary artery bypass grafting or valve replacement has improved significantly but this research shows that more deprived people do not survive as long as those who experience less deprivation, after surgery.

The study clearly showed smoking, obesity and diabetes, had a significant negative impact on survival rates. All these factors were strongly associated with social deprivation.

However, we were also able to show that social deprivation had an independent negative effect on survival that was clinically important and statistically significant even after adjusting for other factors.”

The study showed that social deprivation was a highly significant factor in a patient’s risks of in-hospital mortality after surgery (which was 3.25% amongst the group).

There was an even stronger relationship between social deprivation and death during the five-year follow up after surgery. 5563 patients (12.4%) died during the follow up period. However, there was a 2.4% rise in a patient’s risk of mortality for each point of increase on the deprivation scale.

Professor Nick Freemantle from the University of Birmingham adds: “The relationship between deprivation and mortality was pronounced, but this study raises concerns that the effect of proven healthcare interventions may not be equally distributed across socioeconomic boundaries. The reasons for this relationship are complex, probably including diet, lifestyle and access to healthcare.

 However, this study does highlight the paramount importance of developing rehabilitation programmes both before and after surgery which include aggressive smoking cessation, nutritional and behavioural support to try and reduce these health inequalities.”

ENDS


For further information contact Ben Hill, Press Officer, University of Birmingham, Tel 0121 414 5134, Mob 07789 921163

Notes to Editors

Further information about the study

Background Cardiac surgery offers a number of operations known to carry prognostic benefit. The aim of this study was to assess the effects of social deprivation on survival following cardiac surgery and to understand the influence of potentially modifiable risk factors in these patients.

Methods.  We reviewed prospectively collected data on 44902 patients undergoing adult cardiac surgery between 1997 and 2007 in Birmingham and  North West  England. Social deprivation was calculated using the census based 2001 Carstairs scores. All cause in-hospital and mid-term follow up mortality was obtained from the Office of National Statistics, UK. Prognostic models were developed to examine the additional effect of social deprivation on these endpoints.

Results. In-hospital mortality for all cardiac procedures was 3.25% and mid-term follow up (median 1887 days; range 1180-2725 days) mortality and mid-term mortality was non-linear and risks were higher in the extremes of BMI (P<0.0001). Adjustment for smoking, BMI and diabetes reduced but did not eliminate the effects of social deprivation on mid-term mortality (HR 1.017 95%CI 1.007-1.026;P=0.0004).

Conclusions . Smoking, extremes of BMI and diabetes, which are potentially modifiable risk factors associated with social deprivation are responsible for a significant reduction in survival following surgery, but even after adjusting for these variables social deprivation remains a significant independent predictor of increased mortality risk.