Poulton, Thomas; (2021) Emergency laparotomy and socioeconomic deprivation: the relationship between socioeconomic group, perioperative standards of care, and outcomes for patients undergoing emergency abdominal surgery in England. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Emergency laparotomy is one of the most commonly performed high risk operations, and socioeconomic deprivation has been associated with a range of adverse health outcomes. A narrative systematic review was conducted to explore the existing literature on the association between socioeconomic group and mortality after major intra-abdominal gastrointestinal tract surgery. Where a difference did exist, more deprived cohorts were found to have worse outcomes, which was consistent across a range of time periods, healthcare systems, and outcome measures. To explore any association further, a series of quantitative analyses were undertaken using data from the National Emergency Laparotomy Audit (NELA), merged at patient-level with other national administrative databases. Patients undergoing surgery within England between 1 December 2013 and 30 November 2016 were grouped into quintiles according to the Index of Multiple Deprivation score of the small area containing their usual residence. The aims of this thesis were to explore the following research questions: 1) within this cohort, are there differences in demographics or clinical factors between socioeconomic groups; 2) are there differences in the hospital structures or perioperative processes, according to socioeconomic group; 3) are there differences between socioeconomic groups in risk adjusted 30-day mortality; 4) if mortality differences exist, can they be explained by any variations in acute perioperative standards of care; 5) are there differences in the rates of major complications between socioeconomic groups; 6) is longer term survival sensitive to socioeconomic group, major complications, and the interaction between the two? Patients from the most deprived quintile of areas had higher risk-adjusted 30-day mortality. However, within the English NHS more socioeconomically deprived patients received treatment which was generally of as good quality as those from the least deprived quintile, based on the measures used in NELA. While within- and between-hospital variations in processes of care did exist, no evidence was found that these variations explained the observed differences in outcomes. The differences in mortality continued in longer term survival analysis, but there was no evidence that more deprived patients were more likely to suffer serious postoperative complications, or that there was a significant association between risk-adjusted survival and the interaction between complications and socioeconomic group. Socioeconomic deprivation is a predictor of higher mortality after emergency laparotomy, but acute perioperative standards of care within the NHS in England are generally consistent between socioeconomic groups and are not a driver of the outcome differences between socioeconomic groups. While clinicians and policy makers should be mindful of the influence socioeconomic deprivation has on health, the existing NHS structures appear to provide equitable acute perioperative care. This shows that addressing inequity of surgical outcomes based on socioeconomic disparities requires a focus on the broader social determinants of health and not just the standards of healthcare at the time of an acute illness. In addition, attention could be given to developing targeted interventions to prevent post-discharge deterioration and mortality in more deprived patients.

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