Disparity in clinical outcomes after cardiac surgery between private and public (NHS) payers in England
Disparity in clinical outcomes after cardiac surgery between private and public (NHS) payers in England
Background: there is little known about how payer status impacts clinical outcomes in a universal single-payer system such as the UK National Health Service (NHS). The aim of this study was to evaluate the relationship between payer status (private or public) and clinical outcomes following cardiac surgery from NHS providers in England.
Methods: the National Adult Cardiac Surgery Audit (NACSA) registry was interrogated for patients who underwent adult cardiac surgery in England from 2009 to 2018. Information on socioeconomic status were provided by linkage with the Iteration of the English Indices of Deprivation (IoD). The primary outcome was in-hospital mortality. Secondary outcomes included incidence of in-hospital postoperative cerebrovascular accident (CVA), renal dialysis, sternal wound infection, and re-exploration. To assess whether payer status was an independent predictor of in-hospital mortality, binomial generalized linear mixed models (GLMM) were fitted along with 17 items forming the EuroSCORE and the IoD domains.
Findings: the final sample consisted of 280,209 patients who underwent surgery in 31 NHS hospitals in England from 2009 to 2018. Of them, 5,967 (2.1%) and 274,242 (97.9%) were private and NHS payers respectively. Private payer status was associated with a lower risk of in-hospital mortality (OR 0.79; 95%CI 0.65 – 0.97;P = 0.026), CVA (OR 0.77; 95%CI 0.60 – 0.99; P = 0.039), need for re-exploration (OR 0.84; 95%CI 0.72 – 0.97; P = 0.017) and with non-significant lower risk of dialysis (OR 0.84; 95%CI 0.69 – 1.02; P = 0.074). Private payer status was found to be independently associated with lower risk of in-hospital mortality in the elective subgroup (OR 0.76; 95%CI 0.61 – 0.96; P = 0.020) but not in the non-elective subgroup (OR 1.01; 95%CI 0.64 – 1.58; P = 0.976). Interpretation: In conclusion, using a national database, we have found evidence of significant beneficial effect of payer status on hospital outcomes following cardiac surgery in favour of private payers regardless their socioeconomic factors.
Benedetto, Umberto
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Dimagli, Arnaldo
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Gibbison, Ben
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Sinha, Shubhra
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Pufulete, Maria
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Fudulu, Daniel
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Cocomello, Lucia
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Bryan, Alan J.
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Ohri, Sunil
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Caputo, Massimo
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Cooper, Graham
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Dong, Tim
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Akowuah, Enoch
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Angelini, Gianni D.
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February 2021
Benedetto, Umberto
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Dimagli, Arnaldo
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Gibbison, Ben
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Sinha, Shubhra
eecd2a19-86cc-4fc6-bff7-f9ee89df1c40
Pufulete, Maria
212eb7a6-ebfb-4900-b011-1aecd94fbe3e
Fudulu, Daniel
b415a1b1-f9bd-45ad-889a-496f7a37638a
Cocomello, Lucia
8d451d86-52a2-44cc-8723-0b1a8b16c718
Bryan, Alan J.
6c6ae973-2197-4a6d-bafe-6a4593435226
Ohri, Sunil
9e05e819-e2fa-4665-b492-15bfba532ec0
Caputo, Massimo
745d1132-b50a-434a-843a-d8e7a0d455eb
Cooper, Graham
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Dong, Tim
f76b7cac-8fbf-481b-94b7-01b71ef10377
Akowuah, Enoch
0024554e-404f-4dcd-a932-912b0588693a
Angelini, Gianni D.
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Benedetto, Umberto, Dimagli, Arnaldo, Gibbison, Ben, Sinha, Shubhra, Pufulete, Maria, Fudulu, Daniel, Cocomello, Lucia, Bryan, Alan J., Ohri, Sunil, Caputo, Massimo, Cooper, Graham, Dong, Tim, Akowuah, Enoch and Angelini, Gianni D.
(2021)
Disparity in clinical outcomes after cardiac surgery between private and public (NHS) payers in England.
The Lancet Regional Health - Europe, 1, [100003].
(doi:10.1016/j.lanepe.2020.100003).
Abstract
Background: there is little known about how payer status impacts clinical outcomes in a universal single-payer system such as the UK National Health Service (NHS). The aim of this study was to evaluate the relationship between payer status (private or public) and clinical outcomes following cardiac surgery from NHS providers in England.
Methods: the National Adult Cardiac Surgery Audit (NACSA) registry was interrogated for patients who underwent adult cardiac surgery in England from 2009 to 2018. Information on socioeconomic status were provided by linkage with the Iteration of the English Indices of Deprivation (IoD). The primary outcome was in-hospital mortality. Secondary outcomes included incidence of in-hospital postoperative cerebrovascular accident (CVA), renal dialysis, sternal wound infection, and re-exploration. To assess whether payer status was an independent predictor of in-hospital mortality, binomial generalized linear mixed models (GLMM) were fitted along with 17 items forming the EuroSCORE and the IoD domains.
Findings: the final sample consisted of 280,209 patients who underwent surgery in 31 NHS hospitals in England from 2009 to 2018. Of them, 5,967 (2.1%) and 274,242 (97.9%) were private and NHS payers respectively. Private payer status was associated with a lower risk of in-hospital mortality (OR 0.79; 95%CI 0.65 – 0.97;P = 0.026), CVA (OR 0.77; 95%CI 0.60 – 0.99; P = 0.039), need for re-exploration (OR 0.84; 95%CI 0.72 – 0.97; P = 0.017) and with non-significant lower risk of dialysis (OR 0.84; 95%CI 0.69 – 1.02; P = 0.074). Private payer status was found to be independently associated with lower risk of in-hospital mortality in the elective subgroup (OR 0.76; 95%CI 0.61 – 0.96; P = 0.020) but not in the non-elective subgroup (OR 1.01; 95%CI 0.64 – 1.58; P = 0.976). Interpretation: In conclusion, using a national database, we have found evidence of significant beneficial effect of payer status on hospital outcomes following cardiac surgery in favour of private payers regardless their socioeconomic factors.
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e-pub ahead of print date: 15 December 2020
Published date: February 2021
Additional Information:
Funding Information:
Concept and design: MG and UB. Systematic search design: MG, IH, ADF, MD, and NBR. Statistical analysis design: MG, UB, JHA, JC, PC, JSL, AL, FB, SEF, PJD, DPT, MF, WR, AB, AD, LNG, and NE. Drafting, Concept and design: UB. Statistical analysis design: UB, AD, EA, GDA, Drafting of the manuscript: all authors. of the manuscript: MG, UB, IH, ADF, MD, and NBR. Critical revision: all authors. Funding acquisition: MG. Final approval: all authors, Critical revision: all authors. Final approval: all authors, Requests for data should be directed to the lead author (umberto.benedetto@bristol.ac.uk). Requests will be assessed for scientific rigour before being granted. Data will be anonymised and securely transferred. A data sharing agreement will be required.
Funding: Bristol Biomedical Research Centre (NIHR Bristol BRC).
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© 2020 The Author(s)
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Copyright 2021 Elsevier B.V., All rights reserved.
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Local EPrints ID: 451843
URI: http://eprints.soton.ac.uk/id/eprint/451843
ISSN: 2666-7762
PURE UUID: aba4f6c5-911f-42a1-8e16-3de90ba75984
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Date deposited: 01 Nov 2021 17:31
Last modified: 17 Mar 2024 12:52
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Contributors
Author:
Umberto Benedetto
Author:
Arnaldo Dimagli
Author:
Ben Gibbison
Author:
Shubhra Sinha
Author:
Maria Pufulete
Author:
Daniel Fudulu
Author:
Lucia Cocomello
Author:
Alan J. Bryan
Author:
Sunil Ohri
Author:
Massimo Caputo
Author:
Graham Cooper
Author:
Tim Dong
Author:
Enoch Akowuah
Author:
Gianni D. Angelini
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