Title: Investigating socioeconomic and geographical disparities in vascular surgery rates and outcomes in England
Funder: Department of Health and Social Care

Abstract: Background &ndash; This NIHR Programme Development Grant (PDG) application is for further analysis of data obtained for our recently completed &pound;1.86 million NIHR Programme Grant. Our work on &ldquo;The Design, Development, Commissioning and Evaluation of Patient Focused Vascular Services&rdquo; was undertaken to inform redesign of vascular services in England. This proposal is for further secondary data analysis of pseudoanonymised Hospital Episode Statistics (HES) data on vascular hospital admissions in England, with linked mortality data, from April 2006 to March 2018, supplied by NHS Digital. This project aims to add value by investigating socioeconomic, geographical and ethnic disparities in utilisation and outcomes of vascular services, focussing on: abdominal aortic aneurysm; peripheral artery disease; carotid artery disease; and varicose veins. Research questions 1) What are the socioeconomic and ethnic disparities in vascular surgery rates and outcomes in England? This needs a nuanced approach because prevalence of vascular disease is higher in socioeconomically disadvantaged sections of the population and surgery rates might be expected to be proportionally higher. Is this the case? 2) What are the geographical disparities in vascular surgery rates and outcomes in England? How much of the variation in outcomes is accounted for by higher levels of socioeconomic deprivation in areas with poorer outcomes? And how much does poorer access contribute to poorer outcomes in these areas? What proportion remains unexplained and potentially attributable to variation in service provision, utilisation and other service level factors? 3) The &ldquo;Marmot Review&rdquo; published in 2020 found that socioeconomic and geographical inequalities in health have widened since 2010. What are the trends over time in vascular surgery rates and outcomes? Do they reflect these widening inequalities in health? 4) How has the increasing pressure towards centralisation of vascular services on higher volume centres influenced the association between socioeconomic deprivation and vascular disease outcomes? What is the magnitude of its effect on geographical access to vascular services and what is its effect on geographical disparities in surgery rates and outcomes? 5) What are the effects of the shift to endovascular procedures on the socioeconomic and geographical disparities in vascular surgery rates and outcomes? Has wider use of endovascular procedures narrowed or widened disparities? Methodology The methodology will make explicit use of a population-based analytical approach to address the research questions posed. We plan to use a population-based (ecological) study design using data at a fine geographical scale (lower layer super-output areas (LSOAs)) to examine procedure rates, a population-based cohort study design to examine survival following surgery and a population-based &ldquo;before and after&rdquo; study design with &ldquo;control&rdquo; (comparison) areas to examine the impact of centralisation on socioeconomic and geographical disparities in vascular surgery rates and outcomes. The Index of Multiple Deprivation (IMD) Income Score will be used as the measure of deprivation at the LSOA level. Timescale: 18-month project commencing on 1st October 2020. Anticipated impact &ndash; We anticipate that the results will inform further development of vascular services to address disparities and contribute to the Government s levelling-up agenda.

Lay abstract: Vascular services Vascular services provide specialist surgical treatment and care for patients with a range of conditions which affect blood vessels, principally conditions which affect arteries in the neck (carotid arteries), the main artery in the abdomen (aorta), and arteries and veins in the legs. We recently completed an NIHR Programme Grant entitled &ldquo;The Design, Development, Commissioning and Evaluation of Patient Focused Vascular Services&rdquo;. The work was undertaken to inform the redesign of vascular services in England. Purpose of this application This application is for further analysis of hospital admissions data we obtained from NHS Digital for the Programme Grant. The anonymised data provide details on vascular hospital admissions in England from April 2006 to March 2018. Data were manipulated into a format suitable for our analyses. A Clinical Consensus Group, comprising clinicians involved in the management of vascular disease, provided advice on the process of classifying admissions data into clinically useful categories. Aims of the project This project for further analysis aims to add value by investigating how social and economic circumstances, geography and ethnicity influence the use of vascular services and how long patients survive after surgery. Investigating these variations was not an aim of the main programme grant but our findings indicate that further analysis is important to carry out. For example, one of the findings is that there is a trend towards centralisation of services for major and emergency work (following recommendations indicating that patients operated on in a smaller number of larger centres have better survival rates), but also a tendency for centralisation of minor procedures and investigations. Centralisation may however make it more difficult for people living in economically disadvantaged areas to access services. Data analysis We will carry out statistical analyses to address a range of questions regarding associations between social and economic circumstances, geography and ethnicity, and vascular surgery rates and survival following surgery. Patient and public involvement and engagement Patient representatives will be involved as members of the Project Management Group. In addition, a non-disease specific, public advisory panel at Sheffield Teaching Hospitals NHS Foundation Trust will be engaged in the research. Anticipated benefits Identification of inequalities in vascular health care will provide information and insights that could inform the delivery of vascular services in England. An example of a potential insight is that older people living in economically disadvantaged areas might be less likely to be referred for specialist surgery, resulting in higher death rates in these areas. The results ought to be relevant to government policy makers when the government starts to develop its &ldquo;levelling up&rdquo; policy agenda in relation to health and social care in order to reduce health inequalities.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CARDIOVASCULAR