National Characteristics of Emergency Medical Services in Rural and Frontier Areas: A 2024 Update on Rural-Urban Differences in EMS Care

OBJECTIVES: A prior 2012 national analysis first characterized emergency medical services (EMS) care in frontier and remote areas of the continental United States. We updated that work using the 2024 National EMS Information System (NEMSIS) Public Release Research Dataset to describe rural-urban differences in EMS response characteristics, clinical care, and on-scene mortality, and assess progress. METHODS: We performed an observational study and cross-sectional analysis of 911-initiated EMS responses and qualifying specialty-care interfacility transports reported to NEMSIS in 2024 across 50 states and the District of Columbia. We categorized responses as urban or rural using the NEMSIS-computed Rural Urban Area Commuting Area Codes (RUCA)-derived Urbanicity field (RUCA 7+ rural). Rural-urban differences were tested with t tests, Wilcoxon rank-sum tests, and odds ratios with 95% confidence intervals. A multivariable logistic regression for trauma on-scene death adjusted for age, first systolic blood pressure below 90 mm Hg, first oxygen saturation below 90%, and level of care. RESULTS: Of 60,298,684 EMS records, 45,383,694 met inclusion criteria; rural responses comprised 6.9%. Rural patients were older (58.8 vs 56.1 years; P < 0.001), more likely to be American Indian or Alaska Native (3.4% vs 0.8%; OR 3.16), and more likely to use Medicare (24.2% vs 12.9%; OR 2.56). Air-medical use was concentrated in rural responses (OR 7.14, 95% CI 7.03-7.25). On-scene mortality was higher in rural responses overall (8.3 vs 6.0 per 1,000; OR 1.39) and among trauma responses (OR 2.00, 95% CI 1.84-2.18). After multivariable adjustment for age, vital signs, and level of care, the rural trauma-mortality disparity was attenuated (adjusted OR 1.07; 95% CI 1.00-1.14; P = 0.05). No rural disadvantage was observed for stroke mortality (OR 0.82, broad; OR 0.75, ischemic), in contrast to the 2012 stroke OR of 2.29 (95% CI 1.19-4.40). CONCLUSIONS: Rural EMS responses in 2024 remain distinct from urban responses, with greater air-medical use and higher on-scene mortality. The rural trauma-mortality excess is largely explained by differences in patient physiology at first EMS contact rather than by a geographic effect. The rural stroke-mortality gap observed in 2012 was not present in 2024, consistent with progress in regionalized stroke systems.