Comparison of Surgical Intervention and Mortality for Seven Surgical Emergencies in England and the United States

Sheraz R. Markar, PhD; Alberto Vidal-Diez, PhD; Kirtan Patel, MRCS; Will Maynard, MRCS; Karina Tukanova, MSc; Alice Murray, MRCS; Peter J. Holt, PhD; Alan Karthikesalingam, PhD; George B. Hanna, PhD, FRCS


Annals of Surgery. 2019;270(5):806-812. 

In This Article

Abstract and Introduction


Objective: To examine differences between England and the USA in the rate of surgical intervention and in-hospital mortality for 7 index surgical emergencies.

Background: Considerable international variation exists in the configuration, provision, and outcomes of emergency healthcare.

Methods: Patients aged <80 years hospitalized with 1 of 7 surgical emergencies (ruptured abdominal aortic aneurysm, aortic dissection, appendicitis, perforated esophagus, peptic ulcer, small bowel or large bowel, and incarcerated or strangulated hernias) were identified from English Hospital Episode Statistics and the USA Nationwide Inpatient Sample (2006–2012) and classified by whether they received a corrective surgical intervention. The rates of surgical intervention and population mortality were compared between England and the USA after adjustment for patient demographic factors.

Results: From 2006 to 2012, there were 136,047 admissions in English hospitals and 1,863,626 admissions in US hospitals due to the index surgical emergencies.

Proportion of patients receiving no surgical intervention, for all 7 conditions was greater in the England (OR 4.25, 1.55, 8.53, 1.92, 2.06, 2.42, 1.75) and population in-hospital mortality was greater in England (OR 1.34, 1.67, 2.22, 1.65, 2.7, 4.46, 3.22) for ruptured abdominal aortic aneurysm, aortic dissection, appendicitis, perforated esophagus, peptic ulcer, small bowel or large bowel, and incarcerated or strangulated hernias respectively.

In England (where follow-up was available), lack of utilization of surgery was also associated with increased in-hospital and long-term mortality for all conditions.

Conclusion: England and US hospitals differ in the threshold for surgical intervention, which may be associated with increases in mortality in England for these 7 general surgical emergencies.


The structure of healthcare services varies widely internationally, with a National Health Service (England) and a greater proportion of privatized centers in the USA representing extremes of this variation. This variation in healthcare structure may influence resource availability and provision of services including life-saving treatment in an elective and emergency setting. Furthermore, previous studies in the elective setting have suggested that mortality for several cancer types is greater in England than the USA,[1,2] or that standardized hospital mortality ratios are greater in England than the USA,[3,4] but have not clearly identified the differences in clinical practice that are responsible.

Surgical emergencies are unique among disease states in that corrective interventions are the fundamental component of the care pathway, and the rate of noncorrective intervention has been shown to be a key determinant of population mortality.[5,6] The provision and outcomes of emergency surgery vary widely between countries,[6–8] but it is not known whether differences in the organization of care might be associated with differences in population mortality for surgical emergencies.

The present study aimed to compare the rate of corrective intervention for patients hospitalized for 7 common surgical abdominal emergencies in England and the USA. We sought to examine whether any difference in the rate of intervention between the 2 countries might be seen concomitantly with a discrepancy in condition-specific mortality at population level.