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Table 8 Results of studies exploring surgical outcomes

From: Assessing demographic access to hip replacement surgery in the United Kingdom: a systematic review

Ref. Study timeframe Estimate of surgical need Estimate of surgical outcome Socio-demographic domains Conclusions
[37] January 1998 to March 2005 Harris Hip score to determine severity of hip condition and SF-36 to determine patient quality of life
ASA score to determine surgical risk
Reported patient comorbidities
Harris Hip Score
- Age
- Gender
- Area-based deprivation (Scottish IMD 2006)
- Smoking status
- Comorbidities
- Surgical complications
- Mortality
- ASA score of presurgical fitness
- Quality of life (SF-36 mental and physical)
- 42.6 point improvement in HHS 18 months post-surgery (95% C.I: 41.8–43.4)
- No overall change in mean SF-36 mental score 18 months post-surgery (95% C.I: 0.2–2.5)
- No difference in post-surgical HHS improvement between deprivation quintiles (p = 0.069)
- The most deprived patients had HHS 3.85 points lower pre-surgery (95% C.I: 0.88–6.82), 5.03 points lower 6-months post-surgery (95% C.I: 1.92–8.14) and 4.55 points lower 18-months post-surgery (95% C.I: 0.74–8.35) than the least deprived patients
- Significant difference in physical quality of life between least and most deprived patients: physical SF-36 score was 8.09 points higher (95% C.I: 1.45–14.73)
- Mental-health quality of life only improved in the least deprived: mental SF-36 core was 4.7 points higher (95% C.I: 1.5–7.8)
- No significant differences in length of stay (p = 0.936)
- Significantly fewer smokers in the least deprived quintile compared to most deprived (p < 0.001)
- No significant difference in BMI between quintiles
Gender – no significant differences (p = 0.238)
Comorbidity – no differences
[28] March 2004 to October 2005 POSSUM score to determine physiological risk factors, condition severity and surgical risk
ASA score to determine surgical risk
Reported patient comorbidities
POMS survey to assess post-operative morbidity - Age
- Gender
- Area-based deprivation (IMD 2004)
- White ethnicity
- ASA score
- Surgery duration
- Morbidity
- Surgical risk decreased with decreasing deprivation quintile (Q5-Q1) (p = 0.04)
- 2% increase in predicted surgical risk for most deprived quintile versus least deprived quintile
- No evidence for relationship between SES and postoperative morbidity or infectious morbidity
- No relationship found between post-surgical length of stay and patient SES
- Less deprived patients more likely to be morbidity-free and have left hospital by day 8 post-surgery
[39] January 2006 to November 2008 Charlson index of comorbidity to assess patient comorbidities
Oxford hip score to determine severity of hip condition
SF-12 score to determine patient quality of life
Custom patient satisfaction questionnaire
Oxford hip score
SF-12 score
- Age
- Gender
- Area-based deprivation (Carstairs index)
- Primary diagnosis
- Comorbidities
- Surgical complications
- 90-day mortality rate
- Quality of life (SF-12 score)
- No association was found between SES and prevalence of hip replacement (p = 0.36)
- DEPCATs were significant predictors for mean post-surgical improvement, after adjusting for pre-surgical scores, comorbidity, age, SF-12 score and length of stay (p = 0.001)
-Most deprived patients had mean pre-surgery OHS 5.8 points higher than least deprived patients (p = 0.001)
- Most deprived patients with higher pre-surgery OHS had greater improvement in postoperative score than least deprived patients with lower pre-surgery OHS
- Most deprived patients were more likely to suffer dislocation (p < 0.001) and had higher 90-day mortality risk (p = 0.02)
- More deprived patients were younger at time of surgery (p = 0.04) and had more comorbidities (p = 0.02)
- No association was found between mean Charlson index of comorbidities and SES however (p = 0.09)
- No association was found between SES and BMI (p = 0.5)
[33] April 2009 to February 2011 Oxford hip score to determine severity of hip condition
Patients asked how long their hip problems been present and which comorbidities they have
Oxford hip score
‘Overall, how are the problems now in the (hip/knee) on which you had surgery, compared with before your operation?’
- Age
- Gender
- Area-level deprivation (IMD 2007)
- Non-white ethnicity
- Primary diagnosis
- Comorbidities
- General Health
- Hospital fixed effects
- Most deprived patients had lower pre-surgery OHS than least deprived: most deprived = 15.7, least deprived =19.7
- Most deprived patients had lower post-surgery OHS than least deprived: most deprived = 34.4, least deprived = 39.4
- More deprived patients reported greater hip-related pain and disability 6 months post-surgery, in addition to poor circulation and depression
- 8.2% of most deprived patients reported no improvement post-surgery versus 5.0% of least deprived patients
- Patients in more deprived areas had more self-reported comorbidities (except cancer) and poorer overall health (33% poor health in most deprived versus 18% in least deprived)
- More deprived patients were more likely younger (below 60 years) and of non-white ethnicity
- After adjusting for age, sex, poor pre-surgery health, comorbidities and ethnicity, the association between SES and post-surgery OHS was reduced
[38] 2001 to 2008 Patient comorbidities extracted from HES data Post-surgical length of stay in hospital from admission to discharge (including treatment for surgical complications) - Age
- Gender
- Area-based deprivation (IMD 2004)
- Number of diagnoses
- Hospital activity
- Least deprived patients stay 0.9 days less than the most deprived patients at the same hospital
- Most deprived patients stay 6% longer than other patients in 2001-2002, but this fell to 2% longer by 2007-2008
- Patients over 85 years stayed 7.74 days longer than patients aged 45-54
- Larger differences between age groups dwarf deprivation gradient in length of stay for age
- Patients with 7 or more comorbidities stay 7.18 days longer than patients with one diagnosis
- Length of stay for patients with 7+ comorbidities rose from 58% longer in 2001-2002 to 73% by 2007-2008
Hospital effects
- Positive hospital-level association – hospitals treated lower SES patients have longer lengths of stay (after adjusting for other patient characteristics)
  1. NOTE: SF-36 = 36-Point Short Form Survey; ASA = American Society of Anaesthesiologists Physical Status Classification System; BMI = Body mass index; HHS = Harris Hip Score; POSSUM = Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity; POMS = Postoperative Morbidity Survey; IMD = Indices of Multiple Deprivation; CI = confidence interval; SF-12 = 12-Point Short Form Survey; DEPCAT = deprivation category; OHS = Oxford Hip Score; PROM = Patient-Reported Outcome Measure; HES = Hospital Episode Statistics