A Complex intervention to Address Ethnic and Socioeconomic inequalities in Access to Elective and Acute procedural caRe for Coronary Artery Disease: CAESAR-CAD

Overarching research question: Can a 'learning health system' (LHS) approach reduce ethnic and socioeconomic inequalities in access to elective and acute procedural care for coronary artery disease (CAD) during systemic shocks? Background: CAD is a leading cause of morbidity and mortality in the UK and globally. Compound pressures, including systemic shocks (e.g., COVID-19 pandemic, industrial action, migration policies and winter pressures), present barriers to timely access to procedural care, exacerbating inequalities for socioeconomically deprived and ethnic minority individuals who are deemed high risk for adverse outcomes. The use of large-scale routine data across research and care silos could improve quality and equity of CAD care for these individuals during future shocks. Aims and objectives: Aim: To develop a complex intervention to reduce ethnic and socioeconomic inequalities in elective and acute procedural care (high consequence) for CAD during shocks. Objectives: For elective and acute coronary care by ethnicity and socioeconomic status, to: 1) Assess the impact of compound pressures using regional data (Science), 2) Simulate potential system-level interventions to address real and potential inequalities (Evidence), 3) Design and implement a system-level digital intervention to reduce inequalities in a single regional centre and model its potential impact if upscaled nationally. (Care). Methods: To address my three aims, I will use national, linked electronic health record data accessed through Barts Health NHS Trust and the British Heart Foundation Secure Data Environment (SDE), including disease-specific registries (National Institute of Cardiovascular Outcomes Research) in LHS and complex intervention frameworks. First, I will use Barts Health data to assess the differential impact of compound pressure elements on timeliness and access to elective and acute coronary procedures for CAD by ethnicity and socioeconomic status. I will conduct a realist review with key stakeholders, including a patient advisory group, to better understand potential interventions to reduce ethnic and socioeconomic disparities in timely procedural care. (Aim 1) Second, using agent-based modelling methods, I will simulate system-level intervention scenarios informed by Aim 1 to improve timely access to coronary procedural care. (Aim 2) Third, I will develop a data-driven real-time dashboard linking all key informatics systems at Barts Health NHS Trust to guide operational decision-making, prioritising high-risk individuals based on cardiac risk profile, ethnicity and socioeconomic status. Using mixed methods, I will undertake a feasibility study at Barts Health to examine the efficacy of and refine the digital intervention. The observed effects at a regional level will be employed in models using national SDE data to predict their scaled impact if adopted nationally. (Aim 3) Timelines for delivery: Aim 1(Science):0-15 months Aim 2(Evidence):10-24 months Aim 3(Care):24-60 months Anticipated impact and dissemination: This work will inform regional and national policies to reduce socioeconomic and ethnic inequalities in timely access to elective and acute procedural care for CAD. Intellectual output and dashboard methods will be deposited in online repositories and shared on NHS Innovation, allowing their replication and rollout to other major cardiac and non-cardiac procedure groups. Dissemination will be through media, reports to national bodies and patient advisory groups, and publications.