Case Mix Analysis in Rural Surgical Units in Western Australia: Identifying Research Gaps and Future Directions: A Narrative Review

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BACKGROUND: Rural acute surgical units in Western Australia (WA) are vital but face challenges including workforce shortages, geographical barriers, and resource limitations. Understanding the surgical case mix is crucial for improving service delivery and health outcomes for the 29% of Australians living rurally. This review examines the current state of rural general surgery in WA, focusing on caseload, procedure types, unplanned returns to theater (URTT), mortality, surgeon skills mix, and access to care, to identify critical research gaps. METHODS: A narrative review approach was used, synthesizing information from peer-reviewed literature, health service reports, and workforce data pertinent to rural surgery, particularly in WA. Key areas analyzed include surgeon workload, scope of practice, patient outcomes (URTT, mortality), required surgeon competencies, and barriers to accessing care. RESULTS: Rural general surgeons in Australia, including WA, manage higher procedural volumes per surgeon and a broader scope of practice than metropolitan counterparts, often including endoscopy and procedures outside traditional general surgery (e.g., plastics, urology, and vascular). While outcomes for many general surgical procedures are comparable to urban centers, disparities exist in surgical oncology and trauma mortality, largely linked to access issues and transport times. URTT rates in rural WA are largely unquantified. Workforce shortages persist, with few WA regions meeting surgeon-to-population guidelines, increasing reliance on fly-in-fly-out services. Access is further hindered by geography, transport limitations, and systemic barriers. Training requires a generalist focus with specialist exposure and non-technical skills development. CONCLUSION: Significant research gaps exist regarding URTT rates, specific surgical oncology outcomes, the impact of transport times on trauma morbidity, the detailed skills mix across WA's rural surgeons, and the relative impact of various access barriers. Addressing these gaps through targeted research is essential for developing evidence-based strategies to ensure equitable, high-quality, and sustainable surgical care for rural WAs.

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