Maheswaran R, Tong T, Michaels J, Brindley P, Walters S, Nawaz S. Socioeconomic disparities in abdominal aortic aneurysm repair rates and survival. British Journal of Surgery. 2022 Oct;109(10):958-67.

Background: Abdominal aortic aneurysm (AAA) is more prevalent in socioeconomically disadvantaged areas. This study investigated socioeconomic disparities in AAA repair rates and survival.

Methods: The study used ecological and cohort study designs, from 31 672 census areas in England (April 2006 to March 2018), the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression.

Results: Some 77 606 patients (83.4 per cent men) in four age categories (55–64, 65–74, 75–84, 85 or more years) were admitted with AAA from a population aged at least 55 years of 14.7 million. Elective open and endovascular repair rates were 41 (95 per cent c.i. 23 to 61) and 60 (36 to 89) per cent higher respectively among men aged 55–64 years in the most versus least deprived areas by quintile. This differences diminished and appeared to reverse with increasing age, with 26 (−1 to 45) and 25 (13 to 35) per cent lower rates respectively in men aged 85 years or more in the most deprived areas. Men admitted from more deprived areas were more likely to die in hospital without aneurysm repair. Among those who had aneurysm repair, this was more likely to be for a ruptured aneurysm than among men from less deprived areas. For intact aneurysm repair, they were relatively more likely to have this during an emergency admission. The mortality rate after repair was higher for men from more deprived areas, although the hazard diminished with age. Patterns were unclear for women.

Conclusion: There were clear socioeconomic disparities in operation rates, mode of presentation, and outcome for AAA surgery. Policies are needed to address these disparities.

Michaels JA, Nawaz S, Tong T, Brindley P, Walters SJ, Maheswaran R. Varicose veins treatment in England: population-based study of time trends and disparities related to demographic, ethnic, socioeconomic, and geographical factors. BJS open. 2022 Aug;6(4):zrac077.

Background: Varicose vein (VV) treatments have changed significantly in recent years leading to potential disparities in service provision. The aim of this study was to examine the trends in VV treatment in England and to identify disparities in the provision of day-case and inpatient treatments related to deprivation, ethnicity, and other demographic, and geographical factors.

Method: A population-based study using linked hospital episode statistics for England categorized VV procedures and compared population rates and procedure characteristics by ethnicity, deprivation quintile, and geographical area.

Results: A total of 311 936 people had 389 592 VV procedures between 2006/07 and 2017/18, with a further 63 276 procedures between 2018/19 and 2020/21. Procedure rates have reduced in all but the oldest age groups, whereas endovenous procedures have risen to more than 60 per cent of the total in recent years. In younger age groups there was a 20–30 per cent reduction in procedure rates for the least- deprived compared with the most-deprived quintiles. Non-white ethnicity was associated with lower procedure rates. Large regional and local differences were identified in standardized rates of VV procedures. In the most recent 5-year interval, the North-East region had a three-fold higher rate than the South-East region with evidence of greater variation between commissioners in overall rates, the proportion of endovenous procedures, and policies regarding bilateral treatments.

Conclusions: There are substantial geographical variations in the provision of treatment for VVs, which are not explained by demographic differences. These have persisted, despite the publication of guidelines from the National Institute for Health and Care Excellence, and many commissioners, and providers would seem to implement policies that are contrary to this guidance. Lower rates of procedures in less-deprived areas may reflect treatments carried out in private practice, which are not included in these data.

Michaels JA, Maheswaran R. Conflicting perspectives during guidelines development are an important source of implementation failure. Health Policy. 2023 May 1;131:104801.


In recent years many countries have created national bodies that provide evidence-based guidance and policy relating to the commissioning and provision of healthcare services. However, such guidance often fails to be consistently implemented. The differing perspectives from which guidance is developed is suggested as a significant contributor to these failures. A societal perspective is, necessarily, taken by policy makers, while patients and their healthcare professionals are primarily concerned with an individual perspective. This is particularly likely to impair implementation where national policy objectives, such as cost effectiveness, equity, or the promotion of innovation, are embodied in the guidance, while patients and healthcare professionals may consider it appropriate to over-ride these, based upon individual circumstances and preferences. This paper examines these conflicts with reference to guidance issued by the National Institute of Health and Care Excellence in England. Conflicts are identified between the objectives, values, and preferences of those who develop and those who implement such guidance, with consequent difficulties in providing helpful personalised recommendations. The implications of this for the development and implementation of guidance are discussed and recommendations are made regarding the ways in which such guidance is framed and disseminated.

Michaels, Jonathan; Tong, Thai; Nawaz, Shah; Maheswaran, Ravindra (2023): The failure of evidence-based guidance:  A review of the implementation of national guidelines in vascular services.. The University of Sheffield. Report.

The Vascular Services Research Group at the School of Health and Related Research (ScHARR), University of Sheffield, along with several academic and clinical partners, has been at the forefront of research into the provision, effectiveness, and cost effectiveness of vascular services. In recent years, an extensive NIHR funded programme of research has considered trends and variation in vascular services in England, particularly in relation to socioeconomic, demographic, ethnic and geographical disparities in service provision and outcomes. This report pulls together the evidence that has demonstrated marked variation in the implementation of national evidence-based guidance, examines potential reasons for this variation, and makes recommendations regarding the development and implementation of such guidance in order to improve implementation.

Socioeconomic disparities in surgery for carotid artery disease in England

(BJS Open – in press)

Background: Carotid artery disease (CAD) and stroke are more prevalent in socioeconomically deprived areas. The aim was to investigate socioeconomic disparities in CAD surgery rates and in outcomes following surgery.


Methods: The study used population-based ecological and cohort study designs, 31672 census areas in England, hospital admissions from April 2006 to March 2018, the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression.


Results: 54,377 patients (67% men) from a population aged 55+ years of 14.7 million had CAD procedures (95% carotid endarterectomy (CEA)). CEA rates were 116% (95% confidence interval 101% to 132%) higher in men and 180% (155% to 207%) higher in women aged 55-64 in the most compared with the least socioeconomically deprived areas by quintile. However, this difference diminished and appeared to reverse with increasing age, with 24% (14% to 33%) and 12% (-3 to 24%) lower CEA rates respectively in men and women aged 85+ in the most deprived areas. Patients in deprived areas having CEA were more likely to have been admitted as symptomatic emergency CAD admissions.Mortality, and a combined outcome of mortality or stroke-related readmission, were both worse in patients living in more deprived areas, and were only partially accounted for by the higher prevalence of comorbidities. There was, however, no clear pattern of association between deprivation and elective waiting time for CEA.


Conclusions: These results provide evidence of socioeconomic disparities in surgery for CAD. Clear policies are needed to address these disparities.

Time trends and geographical variation in major lower limb amputation related to peripheral arterial disease in England

(In submission)