Research

Social deprivation and prognostic benefits of cardiac surgery: observational study of 44 902 patients from five hospitals over 10 years

BMJ 2009; 338 doi: 10.1136/bmj.b902 (Published 2 April 2009)
Cite this as: BMJ 2009;338:b902
  1. D Pagano, consultant and reader in cardiothoracic surgery1,
  2. N Freemantle, professor of clinical epidemiology and biostatistics2,
  3. B Bridgewater, consultant cardiothoracic surgeon3,
  4. N Howell, lecturer in cardiothoracic surgery1,
  5. D Ray, head of informatics1,
  6. M Jackson, associate director, quality improvement4,
  7. B M Fabri, consultant cardiothoracic surgeon5,
  8. J Au, consultant cardiothoracic surgeon6,
  9. D Keenan, consultant cardiothoracic surgeon7,
  10. B Kirkup, associate medical director8,
  11. B E Keogh, professor of cardiac surgery9, NHS Medical Director8
  12. on behalf of the Quality and Outcomes Research Unit (QuORU) UHB Birmingham and the North West Quality Improvement Programme in Cardiac Interventions (UKNWQIP)
  1. 1Cardiothoracic Surgical Unit, University Hospital Birmingham Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2TH
  2. 2School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT
  3. 3Department of Cardiothoracic Surgery, South Manchester University Hospital, Manchester M23 9LT
  4. 4Department of Clinical Quality, Liverpool Heart and Chest Hospital NHS Trust, Liverpool L14 3PE
  5. 5Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital NHS Trust, Liverpool
  6. 6Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool FY3 8NR
  7. 7Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Manchester M13 9WL
  8. 8Department of Health, London SW1A 2NS
  9. 9University College Hospital, London W1G 8PH
  1. Correspondence to: D Pagano domenico.pagano{at}uhb.nhs.uk
  • Accepted 18 December 2008

Abstract

Objective To assess the effects of social deprivation on survival after cardiac surgery and to examine the influence of potentially modifiable risk factors.

Design Analysis of prospectively collected data. Prognostic models used to examine the additional effect of social deprivation on the end points.

Setting Birmingham and north west England.

Participants 44 902 adults undergoing cardiac surgery, 1997-2007.

Main outcome measures Social deprivation with census based 2001 Carstairs scores. All cause mortality in hospital and at mid-term follow-up.

Results In hospital mortality for all cardiac procedures was 3.25% and mid-term follow-up (median 1887 days; range 1180-2725 days) mortality was 12.4%. Multivariable analysis identified social deprivation as an independent predictor of mid-term mortality (hazard ratio 1.024, 95% confidence interval 1.015 to 1.033; P<0.001). Smoking (P<0.001), body mass index (BMI, P<0.001), and diabetes (P<0.001) were associated with social deprivation. Smoking at time of surgery (1.294, 1.191 to 1.407, P<0.001) and diabetes (1.305, 1.217 to 1.399, P<0.001) were independent predictors of mid-term mortality. The relation between BMI and mid-term mortality was non-linear and risks were higher in the extremes of BMI (P<0.001). Adjustment for smoking, BMI, and diabetes reduced but did not eliminate the effects of social deprivation on mid-term mortality (1.017, 1.007 to 1.026, P<0.001).

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 after surgery, but even after adjustment for these variables social deprivation remains a significant independent predictor of increased risk of mortality.

Footnotes

  • We thank Matthew Shaw and Vivian Barnet for their help in data collection and analysis.

  • The following consultant surgeons participated in this study:

  • North West Quality Improvement Programme in Cardiac Interventions—John Au, Colin Campbell, John Carey, John Chalmers, Walid Dhimis, Abdul Deiraniya, Andrew Duncan, Brian Fabri, Elaine Griffiths, Geir Grotte, Ragheb Hasan, Tim Hooper, Mark Jones, Daniel Keenan, Neeraj Mediratta, Russell Millner, Nick Odom, Brian Prendergast, Mark Pullan, Abbas Rashid, Franco Sogliani, Paul Waterworth, and Nizar Yonan. Narinda Bhatnagar, Albert Fagan, Bob Lawson, Udin Nkere, Peter O’Keefe, Richard Page, Ian Weir, and David Sharpe left the collaboration during the study period.

  • Quality and Outcomes Research Unit—Robert S Bonser, Timothy R Graham, Stephen J Rooney, Jorge Mascaro, and Ian C Wilson.

  • Contributors: All authors contributed to the design and interpretation of the study. NF conducted the statistical analyses. DP is the guarantor

  • Funding: No funding.

  • Competing interests: None declared.

  • Ethical approval: Not required.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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