Factors contributing to disparities in trauma care between urban vs rural trauma centers: Towards improving trauma care access and quality of care delivery

Abstract

Background

We aim to explore and target factors contributing to disparities in trauma-care outcomes between urban vs rural trauma centers including EMS protocols, trauma centers’ (TC) distribution, infrastructure, and hospital resources.

Methods

A comprehensive literature review was conducted from January 1988 through April 1st, 2024, using Google Scholar, Embase, Cochrane, ProQuest, and PubMed. Included studies evaluated prehospital and in-hospital factors impacting trauma outcomes in urban and rural care settings. Key outcomes of interest were EMS transport times, TC access, inter-hospital transfers, trauma system utilization, and workforce infrastructure.

Results

A review of 29 studies demonstrated prolonged EMS on-scene and transport times, higher undertriage rates, and lower geospatial access to TCs in rural compared to urban settings. Transferring from rural to urban TCs was associated with increased mortality and designating rural TCs as Level III TCs reduced mortality (32 % decrease, p < 0.0001). The unregulated expansion of TCs did not improve patient access or outcomes. Rural hospitals lacked specialized providers, had more hospitalizations (x̄ rural = 685.4 vs x̄ urban = 566.3; p = 0.005), ICU admissions (20.2% vs 11.6 %, p = 0.042), and ventilation requirements (37.8% vs 20.7 %, p = 0.001) among trauma patients.

Conclusions

Rural trauma patients often experience worse outcomes than their urban counterparts, possibly due to longer prehospital times, reduced TC access, and less specialized care. The designation of targeted Level III TCs in rural areas has been associated with improved outcomes. In contrast, unregulated TC expansion has not necessarily enhanced access or outcomes for rural patients.