High stakes, low information, no roads: a qualitative evaluation of determinants of air ambulance utilization and decision making in rural Alaska

BackgroundIn rural Alaska, where most communities lack road access, air ambulances serve as a critical link between remote communities and hospital services. ObjectiveTo examine how air ambulance utilization decisions are made within the rural Alaskan health organization ecosystem. MethodsWe conducted semi-structured interviews with five key stakeholders. Transcripts were analyzed thematically using the Practical, Robust Implementation and Sustainability Model (PRISM). ResultsFour themes emerged that collectively define the structure of the air ambulance decision-making system, each reflecting interactions across multiple PRISM domains: limited formal guidance, logistical constraints affecting transport options, variability driven by communication and clinician risk tolerance, and reliance on unwritten rules. Together, these describe decision-making in a limited information state with incomplete feedback, leading to experiential and locally evolved practices. ConclusionAir ambulance use reflects clinical-logistical constraints rather than critical illness alone. Linking transport decisions to outcomes and developing structured decision support may improve consistency and optimize care delivery.