Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review
Abstract
1. Introduction
2. Methodology
2.1. Definition of Rural Versus Urban
2.2. Systematic Review Protocol
2.3. Screening
2.4. Quality Appraisal
3. Results
3.1. Prehospital Time
3.2. Response Time
3.3. On-scene Time
3.4. Transfer Rates
3.5. Transport Time
3.6. Survival Rates
4. Discussion
4.1. Response Time
4.2. On-Scene Time
4.3. Transport Time Interval
4.4. Survival Rates
4.5. Limitations of This Review
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
Ethical Approval
References
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Author & Year | Study Title | Study Design | Setting & Date (When Stated) | Patient Age Demographics | Study Sample | Outcomes of Interest | CASP Grade |
---|---|---|---|---|---|---|---|
Stripe and Suaman 1991 [30] | A rural-urban comparison of prehospital emergency medical services in Nebraska | Prospective study | The USA. 1988–1989 | Not specified | Patients attending emergency medical services | The rural ambulance provided more services than an urban ambulance. | 5/12 |
Lombardi et al. 1994 [31] | The outcome of out-of-hospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) Study | Cohort study | The USA 1990–1991 | 70 (30–79) | 3243 patients with Cardiac arrest | Total survival rate within the study group was 1.4%. | 6/12 |
Grossman et al. 1997 [32] | Urban-rural differences in the prehospital care of major trauma | Prospective cohort study | The USA. 1991–1992 | Not specified | 459 patients with major trauma | Rural patients had a higher risk of death before arrival (relative risk = 7.4, 95% Confidence Interval (CI) 2.4–22.8) if response time was over 30 min. | 8/12 |
Absalom et al. 1998 [10] | Out-of-hospital cardiac arrests in an urban/rural area during 1991 and 1996: Have emergency medical service changes improved outcome? | Retrospective analysis | The UK 1991–1996 | 67 (13)/70 (13) | 113 cases of out-of-hospital cardiac arrest | Restoration of spontaneous circulation before arrival in the Emergency Department (ED) occurred for patients irrespective of location | 8/12 |
Huang et al. 2001 [33] | Ambulance utilization in metropolitan and rural areas in Taiwan | Retrospective study | Taiwan 1997 | Not specified | Patients attending an emergency medical service | Urban areas had higher call volume and non-transport calls. | 5/12 |
Layon et al. 2003 [34] | Utstein style analysis of rural out-of-hospital cardiac arrest [OOHCA]: Total cardiopulmonary resuscitation (CPR) time inversely correlates with hospital discharge rate | Retrospective analysis | The USA 1998 | 65.9 ± 17.4 | 137 patients with cardiac arrest | Asystole as the initial rhythm, and ED CPR time (8 vs. 15.5 min, p = 0.042 for survivors vs. non-survivors) were the only factors affecting the survival rate. | 6/12 |
Svensson et al. 2003 [35] | Safety and delay time in prehospital thrombolysis of acute myocardial infarction in urban and rural areas in Sweden | Prospective observational study | Sweden 1999–2000 | 65 ± 12/69 ± 10 | 154 patients with myocardial infarction | Patients in urban areas got a higher ejection fraction and fewer symptoms of heart failure after 30 days and a lower 1-year mortality | 7/12 |
Vukmir et al. 2004 [36] | The influence of urban, suburban, or rural locale on survival from refractory prehospital cardiac arrest | Prospective, randomised, double— A blind clinical intervention trial | The USA 1992–1996 | >18 years | 874 patients with cardiac arrest | The survival rate was approximately 13.9% in rural, 14% in suburban, and 23% in urban | 9/12 |
McGuffie et al. 2005 [37] | Scottish urban versus rural trauma outcome study. | Prospective observational study | Scotland 1998–2000 | Urban median = 50 years, rural median = 46 years | 4636 traumatic patients | Rural areas had higher transfers than urban areas (p = 0.002). | 7/12 |
Gonzalez et al. 2006 [20] | Increased Mortality in Rural Vehicular Trauma: Identifying Contributing Factors Through Data Linkage | Retrospective analysis | The USA 2001–2003 | Not specified | 6443 patients with crash injuries | Mortality rates were 4.2% and 2.1% in rural and urban respectively (p = 0.0001). | 6/12 |
Herlitz et al. 2006 [38] | Characteristics and outcome of patients with acute chest pain about the use of ambulances in an urban and a rural area | Cross-sectional study | Sweden 1996–1997 | 71 ± 15/59 ± 17 | Patients with acute chest pain | The Mortality rate was 41.8% among those transported by ambulance and 15.8% among those transported by other means. | 7/12 |
Jennings et al. 2006 [19] | Out-of-hospital cardiac arrest in Victoria: Rural and urban outcomes | Retrospective case series | Australia 2002 to 2003 | 68.4 ± 14.4/65.2 ± 13.4 | 1790 patients with bystander-witnessed cardiac arrest | Rural areas had more bystander cardiopulmonary resuscitation than urban areas. Urban patients with bystander-witnessed cardiac arrest were more likely to discharge from hospital alive than rural patients. | 5/12 |
Moore et al. 2008 [39] | The Northern Ireland Public Access Defibrillation (NIPAD) study: Effectiveness in urban and rural populations | Prospective before and after the intervention, population study. | Northern Ireland 2004–2006 | 67.9 (15.1) | Patients with out-of-hospital cardiac arrests | In the urban areas, rates of survival were 5.1% in 2004 and 1.4% from 2005 to 2006. In the rural areas, survival rates were 2.5% in 2004 and 3.5% in 2005–2006. | 8/12 |
Gonzalez et al. 2009 [29] | Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? | Retrospective analysis | The USA 2001–2002 | Not specified | 45,763 crashed patients | Rural settings had a higher mortality rate than urban settings. 1.78% in rural settings versus 0.90% in urban settings (p < 0.0001). | 7/12 |
Mihalicz et al. 2010 [40] | Urban vs. rural pediatric trauma in Alberta: Where can we focus on prevention? | Retrospective analysis | USA 1996–2006 | 11 (0–17) | 2660 paediatric patients with major trauma | Urban patients had a higher rate of mortality than rural ones (13.0% vs. 10.5%; p = 0.05). | 8/12 |
Shultis et al. 2010 [41] | Striking Rural-Urban Disparities Observed in Acute Stroke Care Capacity and Services in the Pacific Northwest: Implications and Recommendations | Survey study | USA Spring 2008 | ≥45 years | 426 patients with acute stroke | Rural-urban differences were observed, with rural hospitals have a much lower capacity to care for patients with stroke adequately. | 8/12 |
Fatovich et al. 2011 [42] | A comparison of metropolitan vs. major rural trauma in Western Australia | Retrospective study | Australia 1997–2006 | 40.1 ± 22.6 | 3333 patients with major trauma | Rural patients had higher mortality rates than urban. The adjusted odds ratio for death was 1.10 (95% CI 0.66–1.84, p = 0.708). | 7/12 |
Sørensen et al. 2011 [43] | Urban and rural implementation of pre-hospital diagnosis and direct referral for primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction | Prospective analysis | Denmark 2004–2007 | Range = 56 to 79 | 759 patients with myocardial infarctions | Rural areas had an EMS delay of 9 min compared to urban areas, and a median travel distance of 30 km longer. | 6/12 |
Bhuyan et al. 2013 [44] | Rural-urban differences in acute myocardial infarction mortality: Evidence from Nebraska | Retrospective analysis | The USA 2005–2009 and 2011 | 15 to 85+ | Patients with acute myocardial infarction | Urban areas had a lower mortality rate than patients in rural areas. | 8/12 |
Ro et al. 2013 [45] | A trend in epidemiology and outcomes of out-of-hospital cardiac arrest by urbanization level: A nationwide observational study from 2006 to 2010 in South Korea. Resuscitation | nationwide observational study | South Korea. 2006 –2010 | 65 (49–76) | 97291 patients with out-of-hospital cardiac arrest | The survival rate was 3.0% for EMS-assessed Out-of-Hospital Cardiac Arrests (OHCAs) (3.3% for cardiac aetiology and 2.3% for noncardiac aetiology) and 3.6% for EMS-treated OHCAs. | 8/12 |
Aftyka et al. 2014 [22] | Are there any differences in medical emergency team interventions between rural and urban areas? | Retrospective cohort study | Poland 2009 | Not specified | 1624 patients in emergency medical service | Rural areas used cervical collars more than urban areas. | 9/12 |
Horeczko et al. 2014 [46] | Urban and Rural Patterns in Emergent Pediatric Transfer: A Call for Regionalization | National survey data | The USA 1995–2010. | <18 years | 283,232,058 paediatric emergency department visits | Children transferred from rural Emergency Departments (EDs) were more likely to arrive by emergency medical services than children transferred from urban EDs. | 6/12 |
Lipsky et al. 2014 [47] | A comparison of rural versus urban trauma care | Observational cohort study | The USA 1995–1996 | 32.5 (Inter quartile range (IQR): 21.5 –50.5) | 1122 traumatic patients | Mortality was comparable between urban and rural areas. | 5/12 |
Sidney et al. 2014 [48] | Utilization of a State Run Public Private Emergency Transportation Service Exclusively for Childbirth: The Janani (Maternal) Express Program in Madhya Pradesh, India | Cross-sectional facility-based study | India 2012–2013 | Median = 23 | 1126 women delivering in health facilities | Uptake was more in rural areas 44% and poorly educated women 40% | 7/12 |
Masterson et al. 2015 [49] | Urban and rural differences in out-of-hospital cardiac arrest in Ireland | Retrospective analysis | Ireland 2012 | 67(52–78) | 1798 patients with out-of-hospital cardiac arrests | Urban patients had higher hospital discharge rates than rural patients (6% vs. 3%) | 5/12 |
Nordberg et al. 2015 [50] | The survival benefit of dual dispatch of EMS and fire-fighters in out-of-hospital cardiac arrest may differ depending on population density – A prospective cohort study | Prospective cohort study | Sweden 2004, 2006–2009 | 77/72 | 2513 patients with out-of-hospital cardiac arrest | 30-day survival was higher in urban patients than the rural patients. | 7/12 |
Raatiniemi et al. 2015 [51] | Short-term outcome and differences between rural and urban trauma patients treated by mobile intensive care units in Northern Finland: A retrospective analysis | Retrospective analysis | Finland 2012–2013 | 33 (20–55) | 472 traumatic patients | Mortality within 30-day was 23.9% in urban and 13.3% in rural. | 8/12 |
Newgard et al. 2016 [21] | Evaluation of Rural vs. Urban Trauma Patients Served by 9-1-1 Emergency Medical Services. | Secondary analysis of a prospective cohort study | The USA 2011 | 51.6 ± 26.1 | 53,487 traumatic patients | Mortality was 23.9% in urban and 13.3% in rural, however, in the first 24 h 89.6% of rural deaths occurred compared with 64% of urban deaths. | 6/12 |
Beck et al. 2017 [52] | Resuscitation attempts and duration in the traumatic out-of-hospital cardiac arrest | Retrospective analysis | Australia 2008–2014 | Median = 44 years (IQR: 28–60) | 2334 patients with traumatic out-of-hospital cardiac arrest | Arrests occurring in urban regions had significantly higher odds of attempted resuscitation relative to those in rural regions | 8/12 |
Mathiesen et al. 2018 [53] | Effects of modifiable prehospital factors on survival after out-of-hospital cardiac arrest in rural versus urban areas | Prospective analysis | Norway. 2006–2014 | Urban = 70 (58–81), rural = 69 (56–80) | 1138 patients with out-of-hospital cardiac arrest | Urban patients had higher survival rates than urban patients. | 9/12 |
Park et al. 2018 [54] | Dispatcher-assisted bystander cardiopulmonary resuscitation in rural and urban areas and survival outcomes after the out-of-hospital cardiac arrest. | Cross-sectional study | South Korea 2012–2015 | 71 (57–79) | 53,240 patients with out-of-hospital cardiac arrests | Urban patients had higher neurological recovery than rural patients. 1.6% and 6.8% in rural and urban areas, respectively. | 9/12 |
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Alanazy, A.R.M.; Wark, S.; Fraser, J.; Nagle, A. Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review. Int. J. Environ. Res. Public Health 2019, 16, 1728. https://doi.org/10.3390/ijerph16101728
Alanazy ARM, Wark S, Fraser J, Nagle A. Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review. International Journal of Environmental Research and Public Health. 2019; 16(10):1728. https://doi.org/10.3390/ijerph16101728
Chicago/Turabian StyleAlanazy, Ahmed Ramdan M., Stuart Wark, John Fraser, and Amanda Nagle. 2019. "Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review" International Journal of Environmental Research and Public Health 16, no. 10: 1728. https://doi.org/10.3390/ijerph16101728
APA StyleAlanazy, A. R. M., Wark, S., Fraser, J., & Nagle, A. (2019). Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review. International Journal of Environmental Research and Public Health, 16(10), 1728. https://doi.org/10.3390/ijerph16101728