Elsevier

Public Health

Volume 129, Issue 11, November 2015, Pages 1496-1502
Public Health

Original Research
The effect of ethnicity on in-hospital mortality following emergency abdominal surgery: a national cohort study using Hospital Episode Statistics

https://doi.org/10.1016/j.puhe.2015.07.038Get rights and content

Highlights

  • Ethnicity has complex effects on delivery of health care in part related to language barriers.

  • Important in emergency abdominal surgery where delays impact on outcomes (e.g. mortality).

  • Population data suggest ethnicity is not linked with poorer outcomes in this cohort.

  • Ethnicity is not recorded in 5% of this cohort.

  • This represents an important, un-definable group with poorer outcomes.

Abstract

Objectives

Ethnicity has complex effects on health and the delivery of health care in part related to language and cultural barriers. This may be important in patients requiring emergency abdominal surgery where delays have profound impact on outcomes. The aim here was to test if variations in outcomes (e.g. in-hospital mortality) exist by ethnic group following emergency abdominal surgery.

Study design

Retrospective cohort study using population-level routinely collected administrative data from England (Hospital Episode Statistics).

Methods

Adult patients undergoing emergency abdominal operations between April 2008 and March 2012 were identified. Operations were divided into: ‘major’, ‘hepatobiliary’ or ‘appendectomy/minor’. The primary outcome was all cause in-hospital mortality. Univariable and multivariable analysis odds ratios (OR with 95% confidence intervals, CI) adjusting for selected factors were performed.

Results

359,917 patients were identified and 80.7% of patients were White British, 4.7% White (Other), 2.4% Afro-Caribbean, 1.6% Indian, 2.6% Chinese, 3.1% Asian (Other) and 4.9% not known, with crude in-hospital mortality rates of 4.4%, 3.1%, 2.0%, 2.6%, 1.6%, 1.7% and 5.17%, respectively. The majority of patients underwent appendectomy/minor (61.9%) compared to major (20.9%) or hepatobiliary (17.2%) operations (P < 0.001) with an in-hospital mortality of 1.7%, 11.5% and 3.9% respectively. Adjusted mortality was largely similar across ethnic groups except where ethnicity was not recorded (compared to White British patients following major surgery OR 2.05, 95% 1.82–2.31, P < 0.01, hepatobiliary surgery OR 2.78, 95% CI 2.31–3.36, P = 0.01 and appendectomy/minor surgery OR 1.78, 95% 1.52–2.08, P < 0.01).

Conclusions

Ethnicity is not associated with poorer outcomes following emergency abdominal surgery. However, ethnicity is not recorded in 5% of this cohort and this represents an important, yet un-definable, group with significantly poorer outcomes.

Introduction

Ethnicity can be classified by referring to a community of people who share the same culture and/or by referring to an ancestral population which comprises their self-identity.1 Self-reported ethnicity captures both the shared experiences/culture of an individual and their self-identity. According to the 2011 Consensus in some areas of the United Kingdom, especially around London, over 70% of the population report their ethnicity as ‘non-white’.2 Even those who are considered ‘White’ are comprised of a heterogeneous group of residents from Poland, Greece, Romania, Bulgaria and other Eastern countries.

Ethnicity has complex effects on health and the delivery of health care.3, 4, 5 This is a major issue not only in the UK, but also in other countries such as mainland Europe and the United States, both formed of similarly diverse communities.6 Many challenges exist when treating patients from an ethnic background different to that of the health service provider. These can be patient-related including language barriers and cultural barriers e.g. omissions of sensitive elements in the history and adequate expose patients for examinations.7, 8 In addition, there are known provider-related biases linked to racial and ethnic prejudice.9 At a population level, the effects of these factors are difficult to quantify individually, but may have a cumulative effect in delaying diagnosis, treatment and outcomes.

Rapid diagnosis and treatment is essential in patients requiring urgent and emergency abdominal surgery.10, 11, 12 Inappropriate delays produce profound effects on short-term outcomes such as in-hospital mortality, which are widely used as markers of quality.13, 14 Inappropriate delays in care resulting from issues arising from ethnicity would be expected to have a significant impact on those requiring emergency surgery. However, this is unclear.

In England, Hospital Episode Statistics (HES) is an is an administrative dataset that collates information on all National Health Service (NHS) and private patients admitted to NHS hospitals in England on a per-episode basis. HES can monitor population-level outcomes following elective and emergency operations. Self-reported ethnicity is recorded in HES. HES data in recent years have high completeness of ethnic group information (typically exceeding 90%) and accurate in 95% of records when validated.15, 16, 17 There have been notable improvements in ethnicity recording in the past decade.

The aim of this study was to test if variations in outcomes (e.g. in-hospital mortality and length of hospital stay) exist by ethnic group in patients following emergency abdominal surgery.

Section snippets

Hospital Episode Statistics (HES)

A description of the HES database has been published previously.18 In brief, it is an administrative dataset that collates information on all NHS and private patients admitted to NHS hospitals in England. Each admission contains a primary diagnosis and secondary diagnoses which are categorised according to ICD-10 (international classification of diseases, 10th revision),19 along with patient-level demographic data including age, ethnicity and home postal code. This study is exempt from UK

General demographics

During the period of study 359,917 adult patients underwent emergency abdominal operations in England. Demographics are shown in Table 1. There was a fall in the percentage of people in which ethnicity was ‘not stated or known’ from 6.0% to 4.7% over the period studied, but still represented the second largest group (17,563 patients; 4.9% of overall cohort) after White British patients. The percentage of admissions where ethnicity was not recorded by region of residence in England is shown in

Discussion

Variations in-hospital mortality following surgery is important to patients and health service providers. There are a growing number of factors implicated including surgeon case-load, hospital volume and the day of the week operating.22, 23, 24, 25 This study found no evidence of detrimental outcomes for any named ethnic group. This would suggest that there are no identifiable barriers (e.g. cultural, linguistic or other) that impact upon the provision of emergency surgical care. The major

Acknowledgements

The authors would like to thank attendees at the Association of Surgeons of Great Britain and Ireland 2014 for their comments.

Ethical approval

This study is exempt from UK National Research Ethics Committee approval as it involved analysis of an existing dataset of anonymized data for service evaluation. A data sharing agreement with the Health and Social Care Information Centre (HSCIC) to use Hospital Episode Statistics data has been granted. Studies performed at the Department of Informatics, Queen Elizabeth

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