key: cord-0938953-z9dm8dn5
authors: Chen, Yang; Banerjee, Amitava
title: Paying for better care?
date: 2020-12-08
journal: Lancet Reg Health Eur
DOI: 10.1016/j.lanepe.2020.100010
sha: f9b275bde7d19d2d4e5361c0f06e467946e87193
doc_id: 938953
cord_uid: z9dm8dn5

nan

For private patients, there is enhanced access to the named surgeon before and after the operation. To our knowledge, there are no data published on whether private patients are less likely to be cancelled or more likely to be operated on at a certain time of day (for instance first on an elective list) or day of the week, which may lead to differences in outcomes, given evidence that elective surgery carried out later in the week or on the weekend affects mortality [3] . There are no data to support 'more attention from the surgeon' or other members as a mediator of better clinical outcomes. Does the quality of the patient interaction and thoroughness of the senior decision-maker increase? There is evidence linking thoroughness of a surgical ward rounds and reduced in-hospital complications [4] .

Analysis of the factors contributing to the cause of death is crucial in understanding the reasons for reduced in-hospital mortality. For example, it is known that low nurse: patient ratios increase risk inhospital complications and mortality [5] . For CABG, mortality rates are directly associated with "failure to rescue" (death following complications, e.g. stroke, renal failure, re-operation, and prolonged ventilation) [6] . If failure to rescue was a significant factor in the current analysis, and better nursing:patient ratios exist for private-paying patients, then this at least partly explain the findings.

Although the outcomes were adjusted for case-mix based on the EUROSCORE, several important confounding factors require further consideration. For example, the same authors have inspected a larger series of data, identifying an association with ethnicity [7] . Prior studies have examined body-mass index, BMI (demonstrating a U-shaped relationship with mortality), and socioeconomic status, including adjustment for BMI and smoking [8, 9] . Drawing this research together, an avenue for future work might be to identify how large scale electronic health records could offer more detail in these aspects, for instance, to obtain missing data such as cause of death through data-linkage. Despite limitations and inability to deduce causality, such population level studies are important for their generalisability and applicability. By studying 'bright spots' of care and differences in outcomes between groups at an aggregate level, generalisable improvements may be made through policy intervention.

A recent commentary regarding policies and interventions within complex adaptive systems in the COVID-19 context is very relevant [10] :

"precise quantification of particular cause-effect relationships is both impossible. . .and unnecessary (because what matters is what emerges in a particular real-world situation). . . where multiple factors are interacting in dynamic and unpredictable ways, Rather than concluding that 'private payment within an NHS hospital' decreases the mortality associated with cardiac surgery, we need to temper simple conclusions with caveats. In spite of many unknowns, there may be several factors, which when combined, could lead to improved patient care. We have highlighted the potential contribution of nursing ratios combined with consultant level 'attention' post-operatively. Rather than selectively quoting research results out of context in isolated healthcare examples, which may over-estimate private sector performance, a focus on the judicious use of data is essential. Improving data quality and linkage to other datasets will allow future study designs to be strengthened, findings to be reproducible, and policy impact to be more robust.

AB and YC contributed equally to the first draft of the paper and critical revisions.

Dr. Banerjee reports grants from Astra Zeneca, outside the submitted work. Dr. Chen has nothing to disclose.

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

Equivalent outcomes after coronary artery bypass graft surgery performed by consultant versus trainee surgeons: a systematic review and meta-analysis

Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

Surgical ward round quality and impact on variable patient outcomes

The effect of nurse-to-patient ratios on nursesensitive patient outcomes in acute specialist units: a systematic review and meta-analysis

Failure to rescue rates after coronary artery bypass grafting: an analysis from the society of thoracic surgeons adult cardiac surgery database

Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis

Body mass index and mortality among adults undergoing cardiac surgery: a nationwide study with a systematic review and meta-analysis

Is social deprivation an independent predictor of outcomes following cardiac surgery? An analysis of 240 221 patients from a national registry

Will COVID-19 be evidence-based medicine's nemesis?