Mortality in Rural and Urban Emergency and Trauma Care in the United States: A Systematic Review and Meta-Analysis

Objective: Rural hospitals in the United States have fewer specialists, fewer critical care resources, and longer transport distances than urban hospitals, yet national studies disagree on whether rural patients are more likely to die after emergency care. The goal of this study was to determine whether short-term mortality differs between rural and urban patients receiving emergency or trauma care and to estimate the size of the difference. Methods: We conducted a systematic review and meta-analysis reported in line with PRISMA 2020. PubMed was searched on October 11, 2026, for studies published from 2010 onward, supplemented by web searching. Eligible studies were US observational studies that compared rural with urban patients or hospitals and reported mortality after emergency or trauma care. Odds ratios (ORs) were pooled with a DerSimonian-Laird random-effects model, with Hartung-Knapp confidence intervals (CIs) as a sensitivity analysis. Injury and trauma studies formed the primary analysis. Certainty of evidence was rated with GRADE. Results: Of 161 records identified, 14 studies were included and 12 were pooled. Across seven injury and trauma studies, rural setting was associated with higher odds of death (OR, 1.27; 95% CI, 1.07-1.52), with substantial heterogeneity (I^2 = 84%; 95% prediction interval, 0.74-2.19). Across all 12 studies, the pooled OR was 1.23 (95% CI, 1.09-1.40; I^2 = 96%). With Hartung-Knapp intervals, the overall estimate remained significant (95% CI, 1.05-1.45) and the trauma estimate was borderline (95% CI, 0.99-1.64). Study estimates ranged from 0.65 to 1.97. Three pediatric trauma studies gave a consistent estimate (OR, 1.32; 95% CI, 1.18-1.47; I^2 = 0%). Subgroup analyses by rurality definition, age group, and geographic scope did not explain the heterogeneity. Certainty of evidence was very low. Conclusions: In pooled US observational data, rural patients receiving emergency and trauma care had about 23% higher odds of short-term death than urban patients, most consistently among injured children. The evidence is inconsistent, rests on a single-database search with several reports assessed from abstracts only, and should be treated as preliminary. Why rural patients die more often, and at what point in the pathway from injury to definitive care, remains unanswered.