Emergency General Surgery: Impact of Distance and Rurality on Mortality

George Ramsay, Neil Scott, Mohamed Bekheit, Angus Watson, J. J. Jansen* (Corresponding Author), Jared Wohlgemut

*Corresponding author for this work

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There is debate about whether the distance from hospital, or rurality, impacts outcomes in patients admitted under emergency general surgery (EGS). The aim of this study was to determine whether distance from hospital, or rurality, affects the mortality of emergency surgical patients admitted in Scotland.

This was a retrospective population-level cohort study, including all EGS patients in Scotland aged 16 years or older admitted between 1998 and 2018. A multiple logistic regression model was created with inpatient mortality as the dependent variable, and distance from hospital (in quartiles) as the independent variable of interest, adjusting for age, sex, co-morbidity, deprivation, admission origin, diagnosis category, operative category, and year of admission. A second multiple logistic regression model was created with a six-fold Scottish Urban Rural Classification (SURC) as the independent variable of interest. Subgroup analyses evaluated patients who required operations, emergency laparotomy, and inter-hospital transfer.

Data included 1 572 196 EGS admissions. Those living in the farthest distance quartile from hospital had lower odds of mortality than those in the closest quartile (OR 0.829, 95 per cent c.i. 0.798 to 0.861). Patients from the most rural areas (SURC 6) had higher odds of survival than those from the most urban (SURC 1) areas (OR 0.800, 95 per cent c.i. 0.755 to 0.848). Subgroup analysis showed that these effects were not observed for patients who required emergency laparotomy or transfer.

EGS patients who live some distance from a hospital, or in rural areas, have lower odds of mortality, after adjusting for multiple covariates. Rural and distant patients undergoing emergency laparotomy have no survival advantage, and transferred patients have higher mortality.
Original languageEnglish
Article numberzrac032
Number of pages10
JournalBJS Open
Issue number2
Early online date25 Apr 2022
Publication statusPublished - 25 Apr 2022

Bibliographical note

This work was made possible by a grant from NHS Grampian and NHS Highlands Endowment Funding. No funding was received from the National Institutes of Health (NIH); Wellcome Trust; or Howard Hughes Medical Institute (HHMI).

The authors acknowledge the support of the eDRIS Team (Public Health Scotland) for their involvement in obtaining approvals, provisioning, and linking data, and the use of the secure analytical platform within the National Safe Haven. We also acknowledge P. Murchie for support with contextualizing the work within the rural medical practitioner literature.

Data Availability Statement

Supplementary material is available at BJS Open online.


  • comorbidity
  • inpatients
  • laparotomy
  • scotland
  • diagnosis
  • mortality
  • transfer technique
  • emergency surgical procedure
  • General Surgery
  • Lower Gastrointestinal Surgery
  • Upper Gastrointestinal Surgery
  • Acute Care Surgery


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