Inequality in healthy lifespan following surgery: a longitudinal population study

BackgroundSurgery is a widely used treatment option but the impact of surgery on long-term disease across socioeconomic groups is unknown. MethodsLongitudinal population study using linked primary and secondary care data describing adults ([≥]18 years) in England recorded in the Clinical Practice Research Datalink (CPRD) between 1st January 2012 and 31st December 2021. Socioeconomic deprivation was defined using the Index of Multiple Deprivation (IMD). The exposure was surgery and primary outcome was long-term disease. Data are presented as n (%), median (IQR), and adjusted hazards ratios (HR) with 95% confidence intervals. FindingsOf 18,329,659 people, 8,951,145 (48{middle dot}8%) underwent surgery. 78{middle dot}6% of index surgeries were elective (n=7,032,475), 21{middle dot}4% were emergency (n=1,918,670). Amongst surgical patients, 4,741,188 (52{middle dot}0%) were women, 3,540,136 (39{middle dot}6%) from the most deprived deciles (IMD 1-4) and 994,595 (11{middle dot}1%) from a minority ethnic group. Age-standardised rates of surgery were higher in deprived individuals (comparative rate ratio IMD 1 vs. IMD 10 elective: 1{middle dot}11 (95% CI 1{middle dot}11-1{middle dot}11), emergency: 1{middle dot}54 (1{middle dot}54-1{middle dot}54)). Age at first surgery was 42 (27-60) years for elective and 42 (25-65) years for emergency surgery overall, but lower for people from IMD 1-4 (elective: 39 (26-57) years, emergency: 38 (24-60) years). Rates of long-term disease increased following both elective (baseline 19{middle dot}6%, three years 24{middle dot}5%) and emergency surgery (baseline 10{middle dot}3%, three years 12{middle dot}3%). Risk of new long-term disease following surgery increased with increasing levels of deprivation (IMD 1 vs. IMD 10 elective: HR 1{middle dot}46 (1{middle dot}45-1{middle dot}48), emergency: HR 1{middle dot}46 (1{middle dot}44-1{middle dot}48)). InterpretationSurgical treatment is strongly associated with the onset of long-term disease and factors which limit healthy life expectancy. Surgery occurs at a younger age among socioeconomically deprived groups and may be linked to health inequalities. Similar but more complex patterns of inequality were seen in minority ethnic groups. FundingBarts Charity and UK Academy of Medical Sciences. Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSThe impact of surgery on long-term health outcomes beyond mortality and surgical complications such as persistent pain is unknown. People from deprived socioeconomic and minority ethnic groups experience increased risks of postoperative complications, readmissions, and death. We searched PubMed, for English language publications in adults aged over 19 years, over the last 10 years to 10th February 2026 using the following search terms: (surg* OR operat*) AND (long-term outcome OR chronic disease OR comorbidit* OR co-morbidit* OR multimorbidit* OR multi-morbidity*) AND (ethnic* OR race OR racial OR socio* OR depriv* OR ineq* OR disparit*). We identified 7,979 reports. To our knowledge, no previous studies have examined the development of long-term disease following surgery or differences in long-term outcomes following surgery between different socioeconomic and ethnic groups. Added value of this studyThis large national cohort study is to our knowledge the first to examine the relationship between surgery and onset of long-term disease. We included over 18{middle dot}3 million individuals, of whom 48{middle dot}8% underwent a surgical procedure during the study period. 5% of elective surgical patients and 2% of emergency surgical patients developed new long-term disease within three years of surgery. Accounting for differences in age, people from the most deprived decile experienced 11% higher rates of elective and 54% higher rates of emergency surgery compared to the least deprived. People in the most deprived decile underwent their first surgery nearly ten years earlier than those in the least deprived decile with a 46% higher risk of developing new long-term disease within three years of surgery. Although age standardised rates of surgery were lower, people from minority ethnic backgrounds underwent surgery for the first time up to sixteen years earlier that those from white backgrounds and had similarly had higher risk of developing new long-term disease at three years. Implications of all the available evidenceSurgical treatments are associated with onset of long-term disease. This unexpected consequence should be considered when managing patients expectations when planning surgery with them. There are important inequalities in rates of both elective and emergency surgery, and the age this first occurs, between different socioeconomic and ethnic groups. Those from socioeconomically deprived backgrounds and minority ethnic groups undergo surgery at a younger age and are also at greater risk of developing long-term disease and hence reduced healthy life expectancy. One explanation for this may be differences in lifestyle and disease prevention behaviour. Surgery is therefore an important marker for inequalities in healthy life expectancy. The perioperative period is a key opportunity to better manage long-term health to reduce further inequalities. The patterns of these relationships are complex, and a more detailed understanding is needed to ensure that surgery can be better utilised as an opportunity to improve societal health.