Published 2 April 2009, doi:10.1136/bmj.b721
Cite this as: BMJ 2009;338:b721

Editorials

Social deprivation and poor prognosis after cardiac surgery

Targeting cardiac rehabilitation after surgery at deprived groups is key

Observational studies have shown that health, quality of life, and outcomes of medical interventions are worse in patients from socially deprived areas.^{1 2 3} These inequities seem to apply in private and nationalised healthcare systems for a range of surgical procedures.^{4 5} The founding tenets of the NHS are fundamentally linked to redressing imbalances in health between people from different socioeconomic backgrounds. Our inability to achieve equity in health since the inception of the NHS more than 60 years ago weighs heavily on policy makers and the healthcare community.⁶ The emergence of large disease registers and procedure registers is likely to continue to highlight these inequities.

The linked study by Pagano and colleagues (doi:10.1136/bmj.b902) identifies significant differences in mortality between different socioeconomic groups in 44 902 patients during the index admission and five years after a range of cardiac surgical procedures.⁷ The authors used the census based Carstairs scores as a marker of social deprivation. This score is derived from levels of unemployment, car ownership, overcrowding, and low occupational social class in geographical postcode areas and is arguably as good as any other marker of social deprivation. In their patient group, Pagano and colleagues found a 2.4% increased risk of mortality for each point increment in Carstairs score over a median of five years’ follow-up. These data suggest that a person at the 75th centile of Carstairs score is at 4.7 times greater risk of death compared with someone on the 25th centile. Even though the absolute mortality was low after surgery, around 3%, the difference in risk between affluent and deprived patients is striking. Why should the difference be so large? The median age of patients needing cardiac surgery in this study and more widely in the United Kingdom is about 65 years. By this time, each patient’s postcode will be determined by several factors, including educational achievement, employment status, and economic security, all of which will have been influencing health status throughout life. Patients with social deprivation are therefore more likely to have severe disease and other comorbidities at the time of surgery.

But can this excess risk be modified in the periods before and after cardiac surgery? Pagano and colleagues identified three potentially modifiable cardiovascular risk factors associated with social deprivation—obesity, smoking, and diabetes. A recent study also showed the negative effects of these risk factors on long term mortality after cardiac surgery.⁸ Pagano and colleagues found that after statistical adjustment for these risk factors the effect of deprivation on mortality was reduced by almost a third. This seems to be a good target for relative risk reduction, but clearly other factors—unmeasured and possibly immeasurable—contribute to the remaining excess mortality. Further studies are needed to examine these factors.

Smoking, diabetes, and obesity are all interventional targets in the period before and after cardiac surgery. These should be dealt with aggressively within established cardiac rehabilitation services. However, a recent audit of cardiac rehabilitation provision in the UK suggests that only 73% of patients receive cardiac rehabilitation after coronary artery bypass grafting.⁹ Other studies have highlighted that poorer patients are less likely to attend cardiac rehabilitation because they think that it is unnecessary or because of the practical problems of attending.¹⁰

Despite these challenges, the fact that socially deprived people are more likely to be obese, smoke, and have diabetes highlights the need to target rehabilitation processes at these patients after cardiac surgery. Using the postcode and the derived Carstairs score in the overall clinical assessment and associated management plan before and after surgery might be a useful way of doing this.

Intensive management of risk factors preoperatively by nurses has limited value in patients undergoing cardiac surgery.¹¹ Incentives could be offered to healthcare providers across organisational boundaries to intensively manage smoking cessation, control of diabetes, and obesity in more deprived patients. Indeed, existing governmental policies linked to financial incentives may achieve some benefits. Data are emerging that since the introduction of the quality and outcomes framework (QOF), a system where general practitioners receive financial benefits on achieving specific targets, use of statins in socially deprived areas has increased significantly.¹² Pagano and colleagues used data gathered between 1996 and 2007, so the effect of the QOF—introduced in 2004—may not yet be fully apparent. If the QOF does continue to narrow the health gap between rich and poor for coronary heart disease and other conditions, then it will have been worth the extra costs.

The overarching marker of social deprivation is poverty. Poverty is commonly understood to be a financial problem, but it can also cause social, familial, cultural, educational, environmental, emotional, and aspirational problems. Narrowing the gap between the health of the rich and the poor can be achieved only by dealing with the root causes early on in life and continuously throughout life. A good start in life—including decent education, adequate housing, and adequate employment opportunities—is most important. Health will follow.

Cite this as: BMJ 2009;338:b721

¹ Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA

Research, doi: 10.1136/bmj.b902

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Breeze E, Jones DA, Wilkinson P, Bulpitt CJ, Grundy C, Latif AM, et al. Area deprivation, social class, and quality of life among people aged 75 years and over in Britain. Int J Epidemiol 2005;34:276-83.[Abstract/Free Full Text]
2. Wilkinson R, Marmot M, eds. Social determinants of health, the solid facts. 2nd ed. WHO, 2003. www.euro.who.int/document/e81384.pdf.
3. Tonne C, Schwartz J, Mittleman M, Melly S, Suh H, Goldberg R. Long-term survival after acute myocardial infarction is lower in more deprived neighbourhoods. Circulation 2005;111:3063-70.[Abstract/Free Full Text]
4. Birkmeyer NJ, Gu N, Baser O, Morris AM, Birkmeyer JD. Socioeconomic status and surgical mortality in the elderly. Med Care 2008;46:893-9.[CrossRef][Web of Science][Medline]
5. Smith JJ, Tilney HS, Heriot AG, Darzi AW, Forbes H, Thompson MR, et al; Association of Coloproctology of Great Britain and Ireland. Social deprivation and outcomes in colorectal cancer. Br J Surg 2006;93:1123-31.[CrossRef][Web of Science][Medline]
6. HM Government. New opportunities, fair chances for the future. 2009. www.hmg.gov.uk/media/9102/NewOpportunities.pdf.
7. Pagano D, Freemantle N, Bridgewater B, Howell N, Ray D, Jackson M, et al. Social deprivation and prognostic benefits of cardiac surgery: observational study of 44 902 patients from five hospitals over 10 years. BMJ 2009;338:b902.[Abstract/Free Full Text]
8. Kunadian B, Dunning J, Millner RWJ. Modifiable risk factors remain significant causes of medium term mortality after first time coronary artery bypass grafting. J Cardiothorac Surg 2007,2:51.
9. British Heart Foundation. The National Audit of Cardiac Rehabilitation. Annual statistical report 2008. 2008. www.cardiacrehabilitation.org.uk/docs/NACR_2008.pdf.
10. Cooper A, Lloyd G, Weinman J, Jackson G. Why patients do not attend cardiac rehabilitation: role of intentions and illness beliefs. Heart 1999;82:234-6.[Abstract/Free Full Text]
11. Goodman H, Parsons A, Davison J, Preedy M, Peters E, Shuldham C, et al. A randomised controlled trial to evaluate a nurse-led programme of support and lifestyle management for patients awaiting cardiac surgery "Fit for surgery: fit for life" study. Eur J Cardiovasc Nurs 2008;7:189-95.[CrossRef][Web of Science][Medline]
12. Ashworth M, Lloyd D, Smith RS, Wagner A, Rowlands G. Social deprivation and statin prescribing: a cross-sectional analysis using data from the new UK general practitioner "quality and outcomes framework." J Public Health 2007;29:40-7.[CrossRef]

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