Rural-urban differences in prehospital deaths due to injury in North Carolina

Rural disparities in in-hospital mortality after traumatic injury are well documented. However, less is known about rural-urban differences in prehospital trauma mortality. We evaluated differences in prehospital injury-related deaths between rural, suburban, and urban EMS incidents in North Carolina (NC).

Data on EMS responses for injury-related 9-1-1 calls from 7/1/2020-6/30/2023 were obtained from a statewide database. Eligible injuries were defined as EMS documentation of possible injury or a primary or secondary impression with an injury-related ICD-10-CM code (S00.x-T34.x, T79.x). The primary outcome was an EMS incident disposition of patient dead at the scene. Incident locations were geocoded and classified by Census tract-level rural, suburban, and urban. Covariates included demographics, dispatch complaint, EMS response mode and time, level of care, and injury cause and mechanism. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) between prehospital mortality and rurality.

Of 569,501 eligible EMS responses for injuries, 24% were rural, 15% were suburban, and 61% were urban. Prehospital mortality was 0.86%. Prehospital mortality was significantly higher with rural injuries (adjusted OR 1.54, 95% CI 1.19-1.98) and suburban injuries (adjusted OR 1.76, 95% CI 1.43-2.18) compared to urban injuries. Self-harm, traffic injuries, and penetrating trauma were strongly associated with prehospital mortality.

This statewide study found significant rural-suburban-urban differences in prehospital mortality from injury, after accounting for demographics and incident and injury characteristics. These findings highlight the need for trauma systems to consider the differential burden of prehospital injury mortality across communities.