Rural-Metropolitan Disparities in Time to Common Bile Duct Clearance for Choledocholithiasis

Patients with choledocholithiasis presenting to rural hospitals may require transfer to metropolitan centres for definitive biliary intervention. This study compared access to common bile duct clearance between rural and metropolitan care pathways and examined where delays occurred within the rural referral pathway.

A retrospective cohort study included patients undergoing common bile duct clearance for choledocholithiasis at a tertiary hospital between January 2023 and June 2024. The primary outcome was time from diagnosis to first attempted common bile duct clearance. Secondary outcomes included clearance method and procedural outcomes, inpatient length of stay and cholecystectomy completion rate.

Among 147 patients, 64 were rural and 83 metropolitan; 127 had a pre-operative diagnosis. In this group, median time to first attempted common bile duct clearance was longer for rural than metropolitan patients (70.8 vs. 37.6 h; p < 0.001), with an adjusted median difference of 28.5 h (95% CI 11.2-45.9). Following tertiary hospital admission, there was no evidence of longer time to attempted clearance for rural patients (adjusted median difference -8.8 h, 95% CI -22.2 to 4.6; p = 0.199). First-attempt clearance success and procedure-related complication rates were similar between rural and metropolitan patients. Rural patients had longer cumulative inpatient stays (6.6 vs. 4.0 days; p < 0.001), while tertiary hospital length of stay was similar. Cholecystectomy following endoscopic retrograde cholangiopancreatography was also similar between cohorts.

Rural patients experienced delayed access to attempted common bile duct clearance and longer cumulative hospitalisation despite similar procedural outcomes. The absence of a disparity following tertiary admission suggests that opportunities to improve access lie predominantly within the rural referral and transfer pathway.