The Rural-Urban Divide in EMS Care: A Conversation With Study Author Dr. Chad Wilson

When it comes to saving lives, every second counts in EMS response. Yet, according to a recent analysis of a national EMS database, patients in rural areas are waiting nearly 20 minutes longer for EMS compared to the national average. To make matters worse, these prolonged wait times disproportionately affect patients with a higher rate of severe, high-acuity medical needs.

Presented at the American College of Surgeons Clinical Congress 2025, the study, “Disparities in Timely Access to Prehospital Care in Rural America,” highlights a stark disparity in healthcare access and the critical yet often underfunded role of rural hospitals. To learn more about the data and what it means for the future of rural emergency care, EMS World spoke with the study's senior author, Dr. Chad Wilson, associate professor of surgery at the Baylor College of Medicine.

EMS WORLD: Tell us about the study and the difference between urban and rural response times. What were the broad conclusions you came up against, and where did you get your data from?

CHAD WILSON: Our data comes from the National Emergency Medical Services Information System (NEMSIS). It’s an administrative dataset, so while it isn’t 100% designed for clinical research and has some limitations, it provides an unbiased look at how different EMS services enter their information and response times. We were primarily interested in response times in rural settings, and not surprisingly, those times are higher.

Obviously, it's probably not feasible to expect rural access to healthcare to be identical to what someone experiences living right across the street from Ben Taub Hospital here in Houston. However, if the times are drastically different, it makes living in rural areas hazardous enough that state or federal governments might need to fund solutions to address the disparity. The primary purpose of our data is simply to describe this time disparity.

EMS WORLD: Can you give me some hard facts and numbers from your findings?

WILSON: We compared national versus rural settings, specifically looking at high-acuity patients. At the initial EMS evaluation, high-acuity patients made up 26% of the national calls compared to 39% of the rural calls. At the final evaluation, it was 23% nationally versus 33% in rural settings. This shows a significantly greater proportion of high-acuity patients presenting in the rural setting.

When looking at overall response times for all calls, the national average was 73 minutes, while the rural average was 92 minutes—about a 20-minute difference. For high-acuity cases specifically, the national average is 69 minutes compared to 96 minutes in rural settings. That is almost a 30-minute disparity. For conditions requiring immediate, high-intensity care—like hemorrhage control or decompressing a brain bleed—those 30 minutes are incredibly valuable.

EMS WORLD: Given the data, could this be because people in rural settings perceive they are further away and are simply less likely to call EMS for lower-acuity issues?

WILSON: Our data doesn't explicitly show that, but it is certainly one of the possible etiologies.

EMS WORLD: What conclusions did you draw from your research?

WILSON: I try to lean away from drawing "why" conclusions. The purpose of this study is to demonstrate the disparities. As a researcher, I focus more on analytical conclusions rather than social ones to avoid bias. Depending on your lens, the "why" can change; someone advocating for resources in a rural community will have a very different "why" than someone advocating for resources elsewhere.

That said, I can review our formal conclusions for you. We concluded that rural patients experience multifactorial, systemic barriers to timely medical care, even in emergency or high-acuity situations. This includes prolonged scene and travel times. Furthermore, the hospitals these patients present to reflect the reality of current rural medical care, where prehospital and hospital systems often have fewer funds for personnel, training, and equipment—even as they see greater proportions of high-acuity patients.

We also concluded that rural patients, particularly those with severe injuries, are more likely to be transported to specialty hospitals, which entails longer travel times to gain an appropriate level of care. Critical access hospitals, general hospitals, and low-level trauma centers see the predominant number of rural patients.

Our biggest recommendation was that updating prehospital workflows, offering advanced training for personnel, and keeping rural emergency departments open to stabilize patients may help mitigate these disparities. I strongly emphasize the word may. Whether we should mitigate that effect—and how to balance expectations for rural versus urban access to care—is a question that has to be answered by policymakers, not the scientists generating the data.

EMS WORLD: Where do you expect to go further with this data?

WILSON: We need a better, more granular dataset to understand exactly why it takes longer for patients to get where they're going. Our current data is blunt; it gives us response times and acuity levels, which is good, but lacks other critical variables. For instance, is the main issue access to trauma care, stroke care, acute coronary syndrome, or obstetrical emergencies? Those are four highly time-dependent areas of care, but this dataset doesn't easily differentiate them.

Ideally, the next step is to secure grant funding to collect better data. Most importantly, we need to link EMS data to actual patient outcomes, like mortality rates and hospital lengths of stay. Right now, the EMS dataset is limited to the care that occurs during transport. I work with a Department of Defense-funded study called the LITES dataset that successfully links EMS data to hospital outcomes, but due to funding constraints, it was unfortunately limited to only eight high-volume, urban trauma centers.

EMS WORLD: So basically, it comes down to needing more meaningful data through further studies?

WILSON: Yes, more granular and accurate data. If we can link response times to outcomes, the data becomes much more meaningful. If I could definitively say that this time disparity leads to a higher risk of dying from a specific condition, it would strongly inform policymakers about how aggressively we need to earmark funds for rural EMS services and critical access hospitals.

EMS WORLD: Because if the time difference makes no difference to the outcome, it doesn't matter.

WILSON: Correct. Because we are dealing with trauma, we assume time matters, but we can't fully prove the extent of its significance yet. If we had to spend $300 million to save one life, that isn't viable. But if a $100 million intervention could reduce these times and save a life for every ten patients treated, it becomes incredibly cost-effective and appropriate. That is the next level of data those policymakers need.