title: Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services.
abstract: Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma.
  
  
  
  To describe and evaluate rural vs urban processes of care, injury severity, and mortality among injured patients served by 9-1-1 emergency medical services (EMS).
  
  
  
  This was a preplanned secondary analysis of a prospective cohort enrolled from January 1 through December 31, 2011, and followed up through hospitalization. The study included 44 EMS agencies transporting to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. A population-based, consecutive sample of 67 047 injured children and adults served by EMS (1971 rural and 65 076 urban) was enrolled. Among the 53 487 patients transported by EMS, a stratified probability sample of 17 633 patients (1438 rural and 16 195 urban) was created to track hospital outcomes (78.9% with in-hospital follow-up). Data analysis was performed from June 12, 2015, to May 20, 2016.
  
  
  
  Rural was defined at the county level by 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the Centers for Medicare & Medicaid Services ambulance fee schedule by zip code.
  
  
  
  Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates.
  
  
  
  Of the 53 487 injured patients transported by EMS (17 633 patients in the probability sample), 27 535 were women (51.5%); mean (SD) age was 51.6 (26.1) years. Rural vs urban sensitivity of field triage for identifying patients requiring early critical resources was 65.2% vs 80.5%, and only 29.4% of rural patients needing critical resources were initially transported to major trauma centers vs 88.7% of urban patients. After accounting for transfers, 39.8% of rural patients requiring critical resources were cared for in major trauma centers vs 88.7% of urban patients. Overall mortality did not differ between rural and urban regions (1.44% vs 0.89%; P = .09); however, 89.6% of rural deaths occurred within 24 hours compared with 64% of urban deaths. Rural regions had higher transfer rates (3.2% vs 2.7%) and longer transfer distances (median, 97.4 km; interquartile range [IQR], 51.7-394.5 km; range, 47.8-398.6 km vs 22.5 km; IQR, 11.6-24.6 km; range, 3.5-97.4 km).
  
  
  
  Most high-risk trauma patients injured in rural areas were cared for outside of major trauma centers and most rural trauma deaths occurred early, although overall mortality did not differ between regions. There are opportunities for improved timeliness and access to major trauma care among patients injured in rural regions.
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland.
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland2School of Public Health, Oregon Health & Science University, Portland.
authors.forename: Rongwei
authors.initials: R
authors.lastname: Fu
authors.affiliation: Department of Surgery, University of Washington, Seattle.
authors.forename: Eileen
authors.initials: E
authors.lastname: Bulger
authors.affiliation: John A. Burns School of Medicine, University of Hawaii, Honolulu.
authors.forename: Jerris R
authors.initials: JR
authors.lastname: Hedges
authors.affiliation: Intermountain Injury Control Research Center, Department of Pediatrics, University of Utah, Salt Lake City.
authors.forename: N Clay
authors.initials: NC
authors.lastname: Mann
authors.affiliation: School of Public Health, Oregon Health & Science University, Portland6Injury and Violence Prevention Section, Oregon Health Authority, Portland.
authors.forename: Dagan A
authors.initials: DA
authors.lastname: Wright
authors.affiliation: Emergency Medical Services & Trauma Systems, Oregon Health Authority, Portland.
authors.forename: David P
authors.initials: DP
authors.lastname: Lehrfeld
authors.affiliation: Skamania County Emergency Medical Services, Stevenson, Washington.
authors.forename: Carol
authors.initials: C
authors.lastname: Shields
authors.affiliation: Skamania County Emergency Medical Services, Stevenson, Washington9PeaceHealth Southwest Medical Center, Vancouver, Washington.
authors.forename: Gregory
authors.initials: G
authors.lastname: Hoskins
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland.
authors.forename: Craig
authors.initials: C
authors.lastname: Warden
authors.affiliation: Clark Regional Emergency Services Agency, Vancouver, Washington.
authors.forename: Lynn
authors.initials: L
authors.lastname: Wittwer
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland.
authors.forename: Jennifer N B
authors.initials: JN
authors.lastname: Cook
authors.affiliation: American Medical Response, Portland, Oregon12Clackamas County Fire District 1, Milwaukee, Oregon.
authors.forename: Michael
authors.initials: M
authors.lastname: Verkest
authors.affiliation: Clackamas County Fire District 1, Milwaukee, Oregon.
authors.forename: William
authors.initials: W
authors.lastname: Conway
authors.affiliation: Asante Three Rivers Medical Center Trauma Program, Grants Pass, Oregon.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Somerville
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland.
authors.forename: Matthew
authors.initials: M
authors.lastname: Hansen
mesh_terms: D000328:Adult; D000368:Aged; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009922:Oregon; D010043:Outcome and Process Assessment, Health Care; D010360:Patient Transfer / Q000706:statistics & numerical data; D012424:Rural Population / Q000706:statistics & numerical data*; D014187:Transportation of Patients / Q000706:statistics & numerical data; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014218:Triage; D014505:Urban Population / Q000706:statistics & numerical data*; D014861:Washington; D014947:Wounds and Injuries / Q000401:mortality* / Q000628:therapy