We reviewed evidence of any apparently significant 'rural-urban' health status differentials in developed countries, to determine whether such differentials are generic or nation-specific, and to explore the nature and policy implications of determinants underpinning rural-urban health variations. A comprehensive literature review of rural-urban health status differentials within Australia, New Zealand, Canada, the USA, the UK, and a variety of other western European nations was undertaken to understand the differences in life expectancy and cause-specific morbidity and mortality. While rural location plays a major role in determining the nature and level of access to and provision of health services, it does not always translate into health disadvantage. When controlling for major risk determinants, rurality per se does not necessarily lead to rural-urban disparities, but may exacerbate the effects of socio-economic disadvantage, ethnicity, poorer service availability, higher levels of personal risk and more hazardous environmental, occupational and transportation conditions. Programs to improve rural health will be most effective when based on policies which target all risk determinants collectively contributing to poor rural health outcomes. Focusing solely on 'area-based' explanations and responses to rural health problems may divert attention from more fundamental social and structural processes operating in the broader context to the detriment of rural health policy formulation and remedial effort.

/pdf/addressing-the-health-disadvantage-of-rural-populations-how-51pdrmgjfi.pdf

Addressing the health disadvantage of rural populations: How does epidemiological evidence inform rural health policies and research?

The term “golden hour” is commonly used to characterize the urgent need for the care of trauma patients This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury This concept justifies much of our current trauma system However, definitive references are generally not provided when this concept is discussed It remains unclear whether objective data exist This article discusses a detailed literature and historical record search for support of the “golden hour” concept None is identified

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2001.tb00201.x

The golden hour: scientific fact or medical "urban legend"?

Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort.

Objective Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the ‘golden hour’, the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients. Methods A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality. Results Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury. Conclusion Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.

The influence of prehospital time on trauma patients outcome: a systematic review.

A meta-analysis of prehospital care times for trauma.

Objectives: To compare differences in response times, scene times, and transport times by advanced life-support-trained paramedics to trauma incidents in urban and rural locations. Methods: This report was a prospective cohort study of professional emergency medical services conducted in a five-county area in the state of Washington. Ninety-eight percent of trauma transports are provided by professional paramedics trained in advanced life support. Subjects were included in this study if they qualified as a major trauma victim and were transported or found dead at the scene by one of the region's advanced life support transport agencies between August 1, 1991, and January 31, 1992. The severity of injury was rated using the Prehospital Index. Incident locations were defined as rural if they occurred in a US Census division (a geographic area) in which more than 50% of the residents resided in a rural location. Results: During the 6-month data collection period, advanced life support agencies responded to a total of 459 major trauma victims in the region. A geographic location was determined for 452 of these subjects. Of these, 42% of subjects were injured in urban areas and the remainder in rural areas. The severity of injuries, as determined both by the triage classification (p = 0.17) and the distribution of Prehospital Index scores (p = 0.92), was similar for urban and rural major trauma patients. Twenty-six (5.7%) subjects died at the scene. About one quarter of both groups had a severe injury, as indicated by Prehospital Index score of more than 3. The mean response time for urban locations was 7.0 minutes (median = 6 minutes) compared with 13.6 minutes (median = 12 minutes) for rural locations (p < 0.0001). The mean scene time in rural areas was slightly longer than in urban areas (21.7 vs. 18.7 minutes, p = 0.015). Mean transport times from the scene to the hospital were also significantly longer for rural incidents (17.2 minutes vs. 8.2 minutes, p < 0.0001). Rural victims were over seven times more likely to die before arrival (relative risk = 7.4, 95% confidence interval 2.4-22.8) if the emergency medical services' response time was more than 30 minutes. Conclusions: Response and transport times among professional, advanced life-support-trained paramedics responding to major trauma incidents are longer in rural areas, compared with urban areas.

Pennie Klein

Papers

Urban-rural differences in prehospital care of major trauma.