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Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services

Educational Objective 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.
1 Credit CME
Key Points

Question  What are process and outcome differences among patients injured in rural vs urban areas?

Findings  In this preplanned, secondary analysis of a prospective cohort comparing 1971 rural patients and 65 076 urban patients using 9-1-1 emergency medical services following injury, most rural trauma deaths occurred within 24 hours. In addition, most high-risk rural patients were cared for outside of major trauma centers.

Meaning  Patients injured in rural areas have less access to major trauma care and deaths tend to occur early, suggesting that there are opportunities to optimize rural trauma care.


Importance  Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma.

Objectives  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).

Design, Setting, and Participants  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.

Exposures  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.

Main Outcomes and Measures  Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates.

Results  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).

Conclusions and Relevance  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.

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Article Information

Corresponding Author: Craig D. Newgard, MD, MPH, Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mailcode CR-114, Portland, OR 97239 (newgardc@ohsu.edu).

Accepted for Publication: June 20, 2016.

Published Online: October 12, 2016. doi:10.1001/jamasurg.2016.3329

Author Contributions: Drs Newgard and Fu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Newgard, Hedges, Hansen.

Acquisition, analysis, or interpretation of data: Newgard, Fu, Bulger, Hedges, Mann, Wright, Lehrfeld, Shields, Hoskins, Wittwer, Cook, Verkest, Conway, Somerville, Hansen.

Drafting of the manuscript: Newgard, Fu.

Critical revision of the manuscript for important intellectual content: Bulger, Hedges, Mann, Wright, Lehrfeld, Shields, Hoskins, Warden, Wittwer, Cook, Verkest, Conway, Somerville, Hansen.

Statistical analysis: Newgard, Fu, Hansen.

Administrative, technical, or material support: Newgard, Bulger, Hedges, Lehrfeld, Shields, Wittwer.

Study supervision: Newgard, Bulger, Hedges, Hansen.

Conflict of Interest Disclosures: None reported.

Funding/Support: This project was supported by grant R01CE001837 from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We acknowledge and thank all the participating emergency medical services (EMS) agencies, EMS medical directors, hospitals, trauma centers, and trauma registrars that supported and helped provide data for this project. We also acknowledge the guidance and oversight by study advisory committee members who are not coauthors of this article: Nathan Kuppermann, MD, MPH (University of California, Davis); E. Brooke Lerner, PhD (Medical College of Wisconsin); and Gregory J. Jurkovich, MD (University of Colorado during the study; currently, University of California, Davis). Members of the study advisory committee received financial compensation.

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