Disparity in clinical outcomes after cardiac surgery between private and public (NHS) payers in England

Umberto Benedetto*, Arnaldo Dimagli, Ben Gibbison, Shubhra Sinha, Maria Pufulete, Daniel Fudulu, Lucia Cocomello, Alan J Bryan, Sunil Ohri, Massimo Caputo, Graham Cooper, Tim Dong, Enoch Akowuah, Gianni D Angelini

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

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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.
Original languageEnglish
Article number100003
Number of pages8
JournalThe Lancet Regional Health - Europe
Early online date15 Dec 2020
Publication statusPublished - 1 Feb 2021

Bibliographical note

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).

Publisher Copyright:
© 2020 The Author(s)

Structured keywords

  • Bristol Heart Institute
  • Anaesthesia Pain and Critical Care


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