Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study

Thomas E Poulton; Ramani Moonesinghe; Rosalind Raine; Peter Martin; National Emergency Laparotomy Audit project team

doi:10.1016/j.bja.2019.08.022

Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study

Br J Anaesth. 2020 Jan;124(1):73-83. doi: 10.1016/j.bja.2019.08.022.

Authors

Thomas E Poulton¹, Ramani Moonesinghe², Rosalind Raine³, Peter Martin⁴; National Emergency Laparotomy Audit project team

Collaborators

National Emergency Laparotomy Audit project team:
Iain D Anderson, Mike G Bassett, David A Cromwell, Emma Davies, Natalie Eugene, Mike P W Grocott, Carolyn Johnston, Angela Kuryba, Sonia Lockwood, Jose Lourtie, Dave Murray, C M Oliver, Carol Peden, Tom Salih, Kate Walker

Affiliations

¹ Health Services Research Centre, National Institute of Academic Anaesthesia, London, UK; Centre for Perioperative Medicine, Department of Targeted Intervention, University College London, London, UK. Electronic address: t.e.poulton@doctors.org.uk.
² Health Services Research Centre, National Institute of Academic Anaesthesia, London, UK; Centre for Perioperative Medicine, Department of Targeted Intervention, University College London, London, UK; Surgical Outcomes Research Centre, University College London, London, UK.
³ Department of Applied Health Research, University College London, London, UK.
⁴ Health Services Research Centre, National Institute of Academic Anaesthesia, London, UK; Department of Applied Health Research, University College London, London, UK.

PMID: 31860444
DOI: 10.1016/j.bja.2019.08.022

Abstract

Background: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups.

Methods: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence.

Results: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association.

Conclusions: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

Keywords: emergency laparotomy; healthcare disparities; mortality; perioperative care; socioeconomic factors; surgery.

Publication types

Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Comorbidity
Emergency Medical Services*
England / epidemiology
Female
Hospitals / statistics & numerical data
Humans
Laparotomy / mortality*
Male
Middle Aged
Perioperative Care / economics
Perioperative Care / standards
Postoperative Complications / economics*
Postoperative Complications / mortality*
Poverty
Risk Adjustment
Socioeconomic Factors*
State Medicine
Young Adult