Learning from Regional Excellence: Geographic Analysis of the National Emergency Laparotomy Audit (NELA) Mortality Improvement
Bhavesh Devkaran, Jodie Murdoch, Khalid Shahzad, John Taylor, Nikhil Mishra, Hemant SharmaAbstract
Background
NELA demonstrates mortality improvement from 11.36% (2016) to 8.15% (2025), representing a 28% relative reduction across 145,163 verified patients. Understanding the geographic distribution of this improvement offers opportunities for knowledge transfer and targeted quality enhancement.
Methods
Longitudinal analysis of NELA data (2016-2025) examined mortality trends across 15 geographic regions. Cross-sectional 2018 analysis of 23,929 patients across 190 hospitals characterised regional variation. Subsequent datasets confirmed patterns: 2022 (65,561 patients, 193 hospitals), 2025 (55,673 patients, 167 hospitals). Process standards, including critical care admission, CT imaging, data completeness, and elderly assessment, were analysed alongside outcomes.
Results
Geographic analysis revealed substantial regional variation, ranging from 5.4% (London-South-West) to 11.3% (Yorkshire & Humber). Excellence concentrated geographically: 60% of London-South-East hospitals achieved <8% mortality, compared with 13.3% in Yorkshire. In 2018, 6,439 patients (26.9%) received care in consistently low-mortality regions, whilst 7,700 patients (32.2%) underwent surgery in higher-mortality regions. North West (3,362 patients, 27 hospitals) achieved 8.4%, demonstrating scalable excellence at volume. Within-region variation suggested individual hospital practices merit investigation. Critical care admissions remained stable (78% to 77.5%), reflecting capacity constraints. CT imaging declined (65% to 54%) before standard redefinition. Data capture decreased (91% to 83%). These patterns suggest mortality improvement mechanisms differ from traditionally measured processes.
Conclusions
Analysis identifies high-performing regions: North-West demonstrates low mortality at scale (8.4%), London South West achieves exceptional outcomes (5.4%). Future initiatives should establish peer-learning networks, conduct site visits to identify transferable practices in surgical technique and perioperative management, and address infrastructure constraints, particularly in critical care capacity.