Title
Unequal Paths to Care: How Region, Rurality, and Deprivation Shape Transport to Verified Trauma Centers Among the Critically Injured
Summary
A large U.S. study found major geographic and socioeconomic differences in how critically injured patients are transported to verified trauma centers, with outcomes varying by region, rurality, and neighborhood deprivation.
Background
Severe traumatic injury is a medical emergency where minutes matter. For patients with life-threatening injuries, rapid transport by Emergency Medical Services (EMS) to a verified trauma center can reduce death and disability. Trauma centers are hospitals that are specially equipped and staffed to care for the most seriously injured patients, with higher-level centers offering the broadest surgical, critical care, and specialist resources.
In the United States, not all injured patients have the same chance of reaching such centers quickly. Geography plays a major role: people in rural areas may live far from trauma-capable hospitals, while urban systems may face congestion, triage complexity, and uneven distribution of trauma resources. Socioeconomic conditions may also influence access. Neighborhood disadvantage, often measured by the Area Deprivation Index (ADI), reflects factors such as income, education, employment, and housing quality. Communities with higher deprivation may face more barriers to timely, high-quality emergency care.
This study examined whether transport to verified trauma centers differs by U.S. region, rurality, and neighborhood deprivation among critically injured adults who met nationally recognized field triage criteria.
Study Methods
The investigators used the National Emergency Medical Services Information System (NEMSIS), a large national database that captures EMS encounters across the United States. They identified critically injured patients transported by EMS from 2018 through 2022 who met the Centers for Disease Control and Prevention’s field triage criteria for trauma center transport.
The analysis also incorporated maps of ZIP codes containing verified trauma centers at Levels I through V, using data from major trauma organizations, including the American College of Surgeons, the Trauma Center Association of America, and the American Trauma Society.
Patients were grouped by U.S. region: Northeast, Midwest, South, and West. The researchers also classified the scene of injury by urban or rural setting. Neighborhood disadvantage was measured using the Area Deprivation Index at the census block group level and divided into tertiles:
1. Low deprivation
2. Moderate deprivation
3. High deprivation
The main outcome was whether critically injured patients were transported to a verified trauma center or to a ZIP code containing one. Statistical comparisons were made across regions, rurality categories, and deprivation levels.
Key Findings
The study included 36,897,269 critically injured patients who met the inclusion criteria. Of these, 19,874,008 patients, or 53.86%, were transported to a trauma center.
When the data were examined by rurality, the proportions were remarkably similar overall:
– Rural areas: 7,608,704 patients, or 54.01%, were taken to a trauma center
– Urban areas: 12,265,304 patients, or 53.77%, were taken to a trauma center
At first glance, this suggests little difference between rural and urban settings overall. However, the regional breakdown revealed much more variation.
The Northeast had the lowest proportion of critically injured patients transported to a trauma center, while the Midwest had the highest:
– Northeast: 44.04%
– Midwest: 67.40%
This difference was statistically significant (P < .001).
When rural and urban settings were examined within each region, important gaps became visible. In the Northeast:
– Rural areas: 35.33% of critically injured patients were transported to a trauma center
– Urban areas: 46.92% were transported to a trauma center
In the Midwest:
– Rural areas: 65.47%
– Urban areas: 68.57%
These regional differences were also statistically significant (P < .001).
The pattern associated with deprivation was especially notable. Patients injured in more disadvantaged ZIP codes had a higher percentage of transport to trauma centers than those in more advantaged ZIP codes, even after accounting for rurality:
– More disadvantaged areas: 56%
– More advantaged areas: 47%
This finding may seem counterintuitive, but it likely reflects a complex mix of factors, including where trauma centers are located, how EMS systems are organized, population density, and the fact that disadvantaged urban areas may be closer to major trauma hospitals. It does not necessarily mean care is more equitable in these communities; rather, it suggests that neighborhood deprivation and geography interact in complicated ways.
What the Results Mean
This study shows that access to trauma care in the United States is not uniform. The chance that a critically injured patient reaches a verified trauma center depends strongly on where the injury occurs.
The regional variation is striking. The Northeast, despite being densely populated and home to many hospitals, had the lowest trauma-center transport rate. That may reflect differences in EMS protocols, trauma system design, patient distribution, or hospital network structure. By contrast, the Midwest had the highest transport rate, which may reflect more centralized trauma systems or more consistent triage to designated centers.
The rural-urban differences were not large overall, but they became important when paired with region. This is a key point: rurality alone does not fully explain access to trauma care. The local trauma system, transport distances, road infrastructure, and regional policy all matter.
The association with neighborhood deprivation also highlights that social context influences emergency care. Communities with greater socioeconomic disadvantage may have different patterns of trauma incidence, EMS response, hospital placement, and transfer behavior. In some settings, disadvantage may increase proximity to large urban trauma centers, improving the odds of direct transport. But deprivation is still linked to many other health risks and structural barriers, so higher transport rates should not be mistaken for better overall outcomes.
Why This Matters Clinically
For severely injured patients, the first transport decision can shape survival. If EMS takes a patient to a non-trauma hospital when a trauma center is more appropriate, care may be delayed. This is called undertriage. The opposite problem, overtriage, can send patients with less severe injuries to trauma centers unnecessarily, potentially straining limited resources.
Good trauma triage aims to balance these risks. The present findings suggest that national triage performance is uneven and influenced by factors beyond the patient’s injury severity. That means quality improvement efforts should not focus only on individual EMS crews or hospitals. They should also address the structure of regional trauma networks, the distribution of trauma centers, and the unique challenges faced by rural and underserved communities.
Public Health and Policy Implications
The study has several important implications for public health planning and trauma system policy:
1. Region-specific strategies are needed.
A one-size-fits-all approach may not work across the United States. Different regions appear to have different transport patterns and likely different system strengths and weaknesses.
2. Rural access remains a concern.
Even if overall rural versus urban differences appear modest, rural patients may still face longer transport times, fewer nearby trauma centers, and higher dependence on local EMS resources.
3. Socioeconomic factors should be included in trauma planning.
Neighborhood deprivation can help identify communities that may need targeted EMS support, improved hospital access, or tailored trauma system investments.
4. Trauma-center placement matters.
The spatial distribution of verified trauma centers influences whether critically injured patients can reach definitive care quickly. Strategic placement, especially in underserved areas, may improve outcomes.
5. EMS triage protocols should be continuously evaluated.
Triage guidelines are only effective if they function well in real-world conditions. Data-driven reviews can help EMS systems identify where undertriage is occurring and why.
Limitations
As with any large database study, there are limitations. The analysis depends on administrative and system-level data, which may not capture every detail of injury severity, prehospital decision-making, or in-hospital outcomes. The study focused on transport to trauma centers, not directly on mortality, complications, or long-term recovery.
In addition, the presence of a trauma center in a ZIP code does not guarantee identical access for every patient living or injured in that ZIP code. Travel time, traffic, local EMS resources, and hospital capacity can all vary. The Area Deprivation Index is a useful neighborhood measure, but it does not capture every aspect of social disadvantage or individual patient circumstances.
Finally, the study reflects the U.S. trauma system and may not generalize to countries with different EMS models, geography, or hospital networks.
Conclusion
This national study found substantial geographic inequities in EMS transport of critically injured adults to verified trauma centers. Access varied by region, rurality, and neighborhood-level socioeconomic disadvantage. The findings suggest that trauma care access in the United States is shaped by a complex interplay of location, system organization, and social environment.
Improving outcomes will likely require regionally tailored trauma system planning, stronger prehospital triage performance, and targeted support for communities facing geographic and socioeconomic barriers. For critically injured patients, the road to lifesaving care should be as direct and equitable as possible.
