Deprived Patients Research Articles

Fludarabine/Cyclophosphamide Conditioning Regimen in Aplastic Anemia Patients Receiving Matched-Sibling Donor Transplant Is Non-inferior to ATG/Cyclophosphamide: A Single-Center Experience from Pakistan.

The successful outcome of allogeneic hematopoietic stem cell transplant (HSCT) in aplastic anemia patients is driven by suitable donor selection, appropriate conditioning regimen, early intervention, and optimal supportive care after transplant. Pakistan, being a developing country, faces grave economic challenges due to meager health care budget; therefore, cost constraints remain the foremost impediment in optimizing transplant facilities for socioeconomically deprived patients. We conducted a single-center retrospective analysis of aplastic anemia patients (N = 130), who received matched sibling donor transplants from 2011 to 2019, treated with either fludarabine/cyclophosphamide (Flu/Cy) or antithymocyte globulin/cyclophosphamide (ATG/CY) conditioning regimen. Median age was 16 years (IQR, 11-20), and it ranged from 3 to 48 years. The median time from diagnosis to transplant was 3 months (IQR, 2 to 4), and it ranged from 1 to 8 months. The estimated overall survival (OS), relapse-free survival (RFS), and GvHD-free survival (GFS) were found to be 69.0%, 66.7%, and 64.3% in the ATG/Cy group while 76.1%, 72.7%, and 62.5% in the Flu/Cy group, respectively, after a median follow-up of 30 months (IQR, 8 to 55), and it ranged from 0 to 98 months for the study groups. The Flu/Cy regimen was well tolerated and was not associated with increased risk of GvHD. Hence, it may be an appropriate alternative conditioning regimen for developing countries with limited health care resources.

Socioeconomic deprivation status predicts both the incidence and nature of Achilles tendon rupture.

The aim of this study was to describe the epidemiology of Achilles tendon rupture (ATR) and its relationship with socioeconomic deprivation status (SEDS). The hypothesis was that ATR occurs more frequently in socioeconomically deprived patients. Secondary aims were to determine variations in circumstances of injury between more and less deprived patients. A 6-year retrospective review of consecutive patients presenting with ATR was undertaken. The health-board population was defined using governmental population data and SEDS was defined using the Scottish Index of Multiple Deprivation. The primary outcome was an epidemiological description and comparison of incidence in more and less deprived cohorts. Secondary outcomes included reporting of the relationship between SEDS and patient and injury characteristics with univariate and binary logistic regression analyses. There were 783 patients (567 male; 216 female) with ATR. Mean incidence for adults (≥ 18years) was 18.75/100,000 per year (range 16.56-23.57) and for all ages was 15.26/100,000 per year (range 13.51 to 19.07). Incidence in the least deprived population quintiles (4th and 5th quintiles; 18.07 per 100,000/year) was higher than that in the most deprived quintiles (1st and 2nd; 11.32/100,000 per year; OR 1.60, 95%CI 1.35-1.89; p < 0.001). When adjusting for confounding factors, least deprived patients were more likely to be > 50years old (OR 1.97; 95%CI 1.24-3.12; p = 0.004), to sustain ATR playing sports (OR 1.72, 95%CI 1.11-2.67; p = 0.02) and in the spring (OR 1.65, 95%CI 1.01-2.70; p = 0.045) and to give a history of preceding tendinitis (OR 4.04, 95%CI 1.49-10.95; p = 0.006). They were less likely to sustain low-energy injuries (OR 0.44, 95%CI 0.23-0.87; p = 0.02) and to be obese (OR 0.25-0.41, 95%CI 0.07-0.90; p ≤ 0.03). The incidence of ATR was higher in less socioeconomically deprived populations and the hypothesis was therefore rejected. Significant variations in patient and predisposing factors, mechanisms of injury and seasonality were demonstrated between most and least deprived groups, suggesting that circumstances and nature of ATR may vary with SEDS and these are not a homogenous group of injuries. Prognostic Study Level III.

Socioeconomic inequality in access to timely and appropriate care in emergency departments

In publicly-funded healthcare systems, waiting times for care should be based on need rather than ability to pay. Studies have shown that individuals with lower socioeconomic status face longer waits for planned inpatient care, but there is little evidence on inequalities in waiting times for emergency care. We study waiting times in emergency departments (EDs) following arrival by ambulance, where health consequences of extended waits may be severe. Using data from all major EDs in England during the 2016/17 financial year, we find patients from more deprived areas face longer waits during some parts of the ED care pathway. Inequalities in waits are small, but more deprived individuals also receive less complex ED care, are less likely to be admitted for inpatient care, and are more likely to re-attend ED or die shortly after attendance. Patient-physician interactions and unconscious bias towards more deprived patients may be important sources of inequalities.

Is there sex disparity in vascular access at dialysis initiation in France? A mediation analysis using data from the Renal Epidemiology and Information Network registry.

This study was conducted to estimate the direct effect of sex on the proportion of hemodialysis (HD) catheters used at dialysis initiation and to investigate whether predialysis care or socioeconomic status acted as a mediator of the sex effect. Patients who started dialysis between January 1, 2017, and June 30, 2018, in France were included using the data of the Renal Epidemiology and Information Network (REIN) registry. We performed logistic regression to study the association between sex and the proportion of HD catheters used. A mediation analysis with a counterfactual approach was carried out to evaluate whether there was an indirect effect of sex through the proxies of predialysis care {hemoglobin, albumin levels, glomerular filtration rate [GFR] at dialysis initiation} and socioeconomic status. Because an interaction between sex and social deprivation has been identified, we performed a subgroup analysis on deprived and nondeprived patients. The study included 16032 patients, and the sex ratio (male to female) was 10405:5627. In the multivariable analysis, women were associated with a greater risk of starting dialysis with a catheter {odds ratio [OR], 1.32 [95% confidence interval (CI): 1.23-1.42]}. There was an indirect effect of sex on the proportion of HD catheters through proxies for predialysis care {albuminemia <30g/L [OR, 1.08 (95% CI: 1.05-1.10)], hemoglobin <11g/dL [OR, 1.03 (95% CI: 1.02-1.04)], glomerular filtration rate <7mL/min [OR, 1.05 (95% CI: 1.04-1.07)]}. Among deprived patients, there was no direct effect of sex on catheter proportion. Women were associated with a higher risk of starting dialysis through an HD catheter. The effect of sex was mediated by predialysis care, particularly for deprived patients.

Factors predicting long-term physical activity of breast cancer survivors. 5-year-follow-up of the BREX exercise intervention study

Background The benefits of exercise training are well documented among breast cancer (BC) survivors. Patients decrease their physical activity during treatment, and many fail to regain their previous exercise levels. There is therefore a need to define factors supporting long-term physical activity behavior in this patient group, to target supporting interventions aimed at preventing the decline in physical activity (PA). Aim The aim of this study was to determine physical and psychosocial factors explaining long-term physical activity after the adjuvant treatments in BC survivors. Methods Four-hundred forty-six BC survivors followed for 5-years within a randomized exercise trial participated. Factors explaining (1) physical activity after the adjuvant treatments and (2) changes in physical activity in long-term were analyzed using linear regression models and general estimating equation models. Pretreatment leisure-time physical activity (LTPA), demographic, and treatment factors, physical fitness, and quality of life (Qol) at baseline were independent factors. Results Exercise levels increased during the first year, and thereafter remained mostly stable. Higher LTPA, higher fitness level, better Qol and older age at baseline were associated with higher physical activity level after adjuvant treatments (p < .001) in multivariate analysis. Higher levels of fatigue (p < .008) and better emotional functioning (p = .017) at baseline were the main factors associated with increased physical activity during the follow-up. Conclusion Previous exercise habits and Qol after adjuvant chemo-, and radiotherapy were the strongest determinants of long-term physical activity levels in breast cancer survivors. Patients with better emotional functioning increased their exercise activity most as did those patients with higher fatigue levels at baseline. Patients suffering from fatigue after adjuvant treatment managed to increase their exercise levels, in contrast to patients with low emotional functioning, and may benefit from physical exercise interventions. Emotionally deprived patients may benefit from psychosocial support to regain their previous exercise levels.

Waiting Times for Cataract Surgery in Scotland since 2002 and the Effect of Austerity: An Interrupted Time Series Analysis

ABSTRACT Purpose In Scotland, in 2002, the National Waiting Times Unit was launched to reduce NHS waiting times. This was accompanied by a series of waiting time targets across the NHS in Scotland. The purpose of this study is to analyse changes in equality of access to treatment by socioeconomic deprivation associated with this initiative. Methods Trends in annual cataract rates were calculated using secondary care admissions’ Scottish Morbidity Record (SMR01) data on NHS funded elective cataract procedures for patients treated in Scotland from 01 April 1997 to 31 March 2019. An interrupted time series model was used to analyse socioeconomic differences in waiting times by deprivation quintile over three time periods; pre and post waiting time initiative, and post austerity. Results Cataract Surgical Rates more than doubled from 3,723 per million population in 1997/1998 to 7,896 per million population in 2018/2019. Mean waiting time fell from 129.5 days in 1997/1998 to 87.7 days in 2018/2019. Inequality in mean waiting time between most and least deprived cataract patients increased by 1.34 days per quarter between 01 April 1997 and 30 June 2002 and following the waiting time initiative fell by 0.41 days per quarter through to 31 March 2010; and then decreased by 0.002 days per quarter between 01 April 2010 and 31 March 2019. Conclusion The waiting time initiative had a major impact on reducing inequality in waiting times between socioeconomic groups. The onset of austerity in 2010 was associated with a very small and insignificant increase in inequality.

Participation in cancer research in BNSSG, England: A Health Equity Audit 2021.

1565 Background: Cancer is a cause of health inequalities, and nationally, patients from deprived communities have lower participation rates in cancer research. Equitable access to research benefits patients, healthcare organisations and improves applicability of research. Methods: We undertook a health equity audit of participation in cancer research (trials and non-trials based) in Bristol, North Somerset and South Gloucestershire (BNSSG), England from 1.4.2019-30.3.2020 using data from the Acute Trust patient datasets. Comparison cohorts were extracted from a regional primary care dataset (the system wide dataset). Firstly, an incident cancer cohort: diagnosed from 1.11.2019-1.10.2020. Secondly a “living with cancer” cohort: cancer flag in the 5 years prior to 1.7.2021. Deprivation is measured by IMD of home postcode small area (LSOA). Results: Results are presented for the audit in the table below, with 95% confidence intervals where appropriate. Compared to people newly diagnosed with cancer, adults aged 70 or older were 56% less likely to take part in research (OR 0.44, 95% CI 0.39-0.51), and adults aged 80 or older were 77% less likely to take part in research (OR 0.23, 95% CI 0.18-0.29). Compared to people newly diagnosed with cancer, people from the most deprived 20% of the population were 27% less likely to take part in research (OR 0.73, 95% CI 0.88-0.92). The most deprived research participants were more likely to be younger, have one or more comorbidities and a recent emergency admission. Patients from outside BNSSG (18%) appear similar in profile to those from within BNSSG, including for deprivation. Better data are needed for other factors relevant to equity, including ethnicity and Inclusion Health. Conclusions: This health equity audit confirms and quantifies inequities in access to cancer research in our region. Under-representation of deprived and older patients appeared multifactorial in this audit, but further work to understand facilitators and barriers to recruitment is needed. These results are a call to action. [Table: see text]

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair

To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair. We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes. There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage. Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes. Prognostic IV.

Health Inequality Costs

In this issue of The Annals of Thoracic Surgery, Fliegner and colleagues1 investigate the link between socioeconomic deprivation and expenditure for admissions for isolated coronary artery bypass graft surgery. By linking clinical registry data from 8728 coronary artery bypass graft procedures during a 7-year period to Medicare fee-for-service data, they find that spending is higher for socioeconomically deprived patients. This is not surprising as socioeconomic deprivation is linked to higher rates of smoking, excess alcohol consumption, poor diet and obesity—all risk factors of many illnesses and leading causes of death worldwide, including comorbidities that make care more expensive.

Socioeconomic inequality, waiting time initiatives and austerity in Scotland: an interrupted time series analysis of elective hip and knee replacements and arthroscopies.

National Health Service (NHS) waiting times have long been a political priority in Scotland. In 2002, the Scottish government launched a programme of investment and reform to reduce waiting times. The effect on waiting time inequality is unknown as is the impact of subsequent austerity measures. An interrupted time series analysis between the most and least socioeconomically deprived population quintiles since the introduction of waiting time initiative 1 July 2002 and austerity measures 1 April 2010. All NHS-funded elective primary hip replacement, primary knee replacement and arthroscopy patient data in Scotland from 1 April 1997 to 31 March 2019. NHS Scotland funded patients treated in Scotland. Trends and changes in mean waiting time. There were 135,176, 122,883 and 173,976 NHS funded hip replacement, knee replacement and arthroscopy patients, respectively, in Scotland between 1 April 1997 and 31 March 2019. From 1 July 2002 to 31 March 2010, waiting time inequality between the most and least deprived patients fell and increased thereafter. For hip replacements before 1 July 2002, waiting time inequality increased 1.07 days per quarter; this changed at 1 July 2002 with significant slope change of -2.32 (-3.53, -1.12) days resulting in a decreasing rate of inequality of -1.26 days per quarter. On 1 April 2010 the slope changed significantly by 1.84 (0.90, 2.78) days restoring increasing inequality at 0.58 days per quarter. Knee replacements and arthroscopies had similar results. The waiting time initiative in Scotland is associated with a reduction in waiting time inequality benefiting the most socioeconomically deprived patients. Austerity measures may be reversing these gains.

Area Deprivation and Medicare Spending for Coronary Artery Bypass Grafting: Insights From Michigan

BackgroundPrior work has established that high socioeconomic deprivation is associated with worse short- and long-term outcomes for patients undergoing coronary artery bypass grafting (CABG). The relationship between socioeconomic status and 90-day episode spending is poorly understood. In this observational cohort analysis, we evaluated whether socioeconomically disadvantaged patients were associated with higher expenditures during 90-day episodes of care after isolated CABG. MethodsWe linked clinical registry data from 8728 isolated CABG procedures from January 1, 2012, to December 31, 2018, to Medicare fee-for-service claims data. Our primary exposure variable was patients in the top decile of the Area Deprivation Index. Linear regression was used to compare risk-adjusted, price-standardized 90-day episode spending for deprived against nondeprived patients as well as component spending categories: index hospitalization, professional services, post acute care, and readmissions. ResultsA total of 872 patients were categorized as being in the top decile. Mean 90-day episode spending for the 8728 patients in the sample was $55 258 (SD, $26 252). Socioeconomically deprived patients had higher overall 90-day spending compared with nondeprived patients ($61 579 vs $54 557; difference, $3003; P = .001). Spending was higher in socioeconomically deprived patients for index hospitalizations (difference, $1284; P = .005), professional services (difference, $379; P = .002), and readmissions (difference, $1188; P = .008). Inpatient rehabilitation was the only significant difference in post–acute care spending (difference, $469; P = .011). ConclusionsMedicare spending was higher for socioeconomically deprived CABG in Michigan, indicating systemic disparities over and above patient demographic factors.

Socio-economic inequalities in cancer survival: how do they translate into Number of Life-Years Lost?

BackgroundWe aimed to investigate the impact of socio-economic inequalities in cancer survival in England on the Number of Life-Years Lost (NLYL) due to cancer.MethodsWe analysed 1.2 million patients diagnosed with one of the 23 most common cancers (92.3% of all incident cancers in England) between 2010 and 2014. Socio-economic deprivation of patients was based on the income domain of the English Index of Deprivation. We estimated the NLYL due to cancer within 3 years since diagnosis for each cancer and stratified by sex, age and deprivation, using a non-parametric approach. The relative survival framework enables us to disentangle death from cancer and death from other causes without the information on the cause of death.ResultsThe largest socio-economic inequalities were seen mostly in adults <45 years with poor-prognosis cancers. In this age group, the most deprived patients with lung, pancreatic and oesophageal cancer lost up to 6 additional months within 3 years since diagnosis than the least deprived. For most moderate/good prognosis cancers, the socio-economic inequalities widened with age.ConclusionsMore deprived patients and particularly the young with more lethal cancers, lose systematically more life-years than the less deprived. To reduce these inequalities, cancer policies should systematically encompass the inequities component.

Unseen patterns of preventable emergency care: Emergency department visits for ambulatory care sensitive conditions.

ObjectiveAdmissions for ambulatory care sensitive conditions (ACSCs) are often used to measure potentially preventable emergency care. Visits to emergency departments with ACSCs may also be preventable care but are excluded from such measures if patients are not admitted. We established the extent and composition of this preventable emergency care.MethodsWe analysed 1,505,979 emergency department visits (5% of the national total) between 1 April 2015 and 31 March 2017 at six hospital Trusts in England, using International Classification of Diseases diagnostic coding. We calculated the number of visits for each ACSC and examined the proportions of these visits that did not result in admission by condition and patient characteristics.Results11.1% of emergency department visits were for ACSCs. 55.0% of these visits did not result in hospital admission. Whilst the majority of ACSC visits were for acute rather than chronic conditions (59.4% versus 38.4%), acute visits were much more likely to conclude without admission (70.3% versus 33.4%). Younger, more deprived and ethnic minority patients were less likely to be admitted when they visited the emergency department with an ACSC.ConclusionsOver half of preventable emergency care is not captured by measures of admissions. The probability of admission at a preventable visit varies substantially between conditions and patient groups. Focussing only on admissions for ACSCs provides an incomplete and skewed picture of the types of conditions and patients receiving preventable care. Measures of preventable emergency care should include visits in addition to admissions.

Socioeconomic disparities in endometrial cancer survival in Germany: a survival analysis using population-based cancer registry data

PurposeArea-based socioeconomic deprivation has been established as an important indicator of health and a potential predictor of survival. In this study, we aimed to measure the effect of socioeconomic inequality on endometrial cancer survival.MethodsPopulation-based data on patients diagnosed with endometrial cancer between 2004 and 2014 were obtained from the German Centre for Cancer Registry Data. Socioeconomic inequality was defined by the German Index of Socioeconomic Deprivation. We investigated the association of deprivation and overall survival through Kaplan–Meier curves and Cox proportional regression models.ResultsA total of 21,602 women, with a mean age of 67.8 years, were included in our analysis. The observed 5-year overall survival time for endometrial cancer patients living in the most affluent districts (first quintile) was 78.6%. The overall survival rate decreased as the level of deprivation increased (77.2%, 73.9%, 76.1%, 74.7%, for patients in the second, third, fourth, and fifth quintile (most deprived patients), respectively). Cox regression models showed stage I patients living in the most deprived districts to have a higher hazard of overall mortality when compared to the cases living in the most affluent districts [Hazard ratio: 1.20; 95% Confidence interval (0.99–1.47)] after adjusting for age, tumor characteristics, and treatment.ConclusionOur results indicate differences in endometrial cancer survival according to socioeconomic deprivation among stage I patients. Considering data limitations, future studies with access to individual-level patient information should be conducted to examine the underlying causes for the observed disparity in cancer survival.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors.

The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture. A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5years. Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050). The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture. III.

Socio-economic status and 1year mortality among patients hospitalized for heart failure in China.

AimsThis study explored the association between socio‐economic status (SES) and mortality among patients hospitalized for heart failure (HF) in China.Methods and resultsWe used data from the China Patient‐centred Evaluative Assessment of Cardiac Events‐Prospective Heart Failure Study (China PEACE 5p‐HF Study), which enrolled patients hospitalized primarily for HF from 52 hospitals between 2016 and 2018. SES was measured using the income, employment status, educational attainment, and partner status. Individual socio‐economic risk factor (SERF) scores were assigned based on the number of coexisting SERFs, including low income, unemployed status, low education, and unpartnered status. We assessed the effects of SES on 1 year all‐cause mortality using Cox models. We used the Harrell c statistic to investigate whether SES added incremental prognostic information for mortality prediction. A total of 4725 patients were included in the analysis. The median (interquartile range) age was 67 (57–76) years; 37.6% were women. In risk‐adjusted analyses, patients with low/middle income [low income: hazard ratio (HR) 1.61, 95% confidence interval (CI) 1.21–2.14; middle income: HR 1.32, 95% CI 1.00–1.74], unemployment status (HR 1.43, 95% CI 1.10–1.86), low education (HR 1.25, 95% CI 1.03–1.53), and unpartnered status (HR 1.22, 95% CI 1.03–1.46) had a higher risk of death than patients with high income, who were employed, who had a high education level, and who had a partner, respectively. Compared with the patients without SERFs, those with 1, 2, 3, and 4 SERFs had 1.52‐, 2.01‐, 2.45‐, and 3.20‐fold increased risk of death, respectively. The addition of SES to fully adjusted model improved the mortality prediction, with increments in c statistic of 0.01 (P < 0.01).ConclusionsIn a national Chinese cohort of patients hospitalized for HF, low income, unemployment status, low education, and unpartnered status were all associated with a higher risk of death 1 year following discharge. In addition, incorporating SES into a clinical‐based model could better identify patients at risk for death. Tailored clinical interventions are needed to mitigate the excess risk experienced by those socio‐economic deprived HF patients.

Outcomes associated with secondary implant removal and arthrolysis in patients with a painful stiff shoulder after proximal humeral fracture fixation.

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome. Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively. A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS. ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J2022;104-B(1):157-167.

CORR Insights®: How Should We Measure Social Deprivation in Orthopaedic Patients?

CORR Insights®: How Should We Measure Social Deprivation in Orthopaedic Patients?

P-O08 Effect of socioeconomic deprivation on clinical characteristics and outcomes of patients undergoing an emergency appendectomy

Abstract Background Appendicectomy is one of the commonest emergency general surgical operations performed. Previous studies have shown that socioeconomic status (SES) impact outcomes in a number of diseases. Currently, there is no study analysing the impact of SES on the outcome of appendectomy. Our aim was to compare the clinical characteristics and outcomes of adults having an emergency appendectomy between deprived and less deprived SES groups. Methods A multicentre retrospective observational study of all adult patients who had an emergency appendectomy across four hospitals (two district general and two tertiary care hospitals) between August 2018 and November 2020 was performed. Patients were identified through pathology records. Data was extracted from electronic records for demographics, pre-operative (peak) blood results, pre and post-operative imaging, operative details and the clinical outcomes. Patient’s residential address was used to calculate Scottish Index of Multiple Deprivation (SIMD). The patients were grouped by SIMD into a more deprived SES group (SIMD 1-5) and a less deprived SES group (SIMD 6-10) and results compared. Results A total of 1,105 patients (57.5% male) were included. Median age was lower in the more deprived group (35 vs 40 years, p &amp;lt; 0.001). The less deprived group were more likely to be fitter: ASA-1 grade 51.6% vs 43.5%, p = 0.008. There were fewer appendectomies in most deprived decile compared to the least deprived decile (5.2 vs 11.3 per 10,000 population per year, p &amp;lt; 0.001). There was no difference in inflammatory markers, pre-operative imaging, surgical approach, severity of appendicitis and the median length of stay (3 days). However, there were more surgical site infection in the more deprived group (3.4% vs 0.9%, p = 0.006). Conclusions This study demonstrates that SES does impact on the age of presentation and incidence of appendectomy. Surgical site infection were seen more frequently in the more deprived patients undergoing emergency appendectomy. This may be a reflection of the underlying comorbidities.

Trends, geographical variation and factors associated with melatonin prescribing in general practices in England: A practice-level analysis.

An overview of melatonin prescribing trends and variation in England is described in this study. Prescription reimbursement data for melatonin in England were extracted from publicly available primary care datasets between 2008-2019. Melatonin prescribing rates, cost and product license status were described over time. Potential factors associated with melatonin prescribing were investigated using Poisson regression. Melatonin prescribing increased from 2.0 to 19.9 per 1000 people between 2008 and 2019. While prescriptions for licensed products increased from 6.5% to 88.2%, spending on unlicensed products was £10 million and accounted for 23.3% of the total prescription cost in 2019. Practices with a higher proportion of children and older people and those serving more deprived patient populations were associated with a higher rate of prescribing (rate ratio = 1.51, 1.66 and 1.59, respectively). Melatonin prescribing in England has increased exponentially over the last decade, with substantial spending on unlicensed products of unknown quality. Patient-level analysis research is needed.