Where Does the Rural EMS Response-Time Gap Arise? A Town-Level Decomposition of Prehospital Response Intervals in Connecticut

Abstract

Background: Rural communities experience longer emergency medical services (EMS) response times than urban communities, but aggregate response-time measures do not identify where within the response process these differences emerge. Distinguishing delays occurring before unit mobilization from those occurring during travel may identify different targets for EMS system improvement. This study evaluated contemporary geographic differences in EMS response time across Connecticut and decomposed the rural–urban difference into mobilization and travel components. Methods: A cross-sectional ecological analysis was conducted using publicly available municipality-level data from the Connecticut Department of Public Health Office of Emergency Medical Services 2025 Annual Report. All 169 Connecticut municipalities were included and classified by the state as rural (n=91), suburban (n=33), or urban (n=45). Municipality-level mean total EMS response time, first-service-tone-to-en-route time, and en-route-to-scene time were analyzed. Kruskal–Wallis tests assessed differences across geographic classifications, followed by pairwise Mann–Whitney U tests with Holm correction. Rank-biserial correlations were calculated as effect-size measures. Differences in mean tone-to-en-route and en-route-to-scene intervals were additionally used for a descriptive decomposition of the rural–urban component gap. Results:  Municipality-level mean total response time was 12.18 minutes (SD=3.63) among rural municipalities, 8.83 minutes (SD=1.82) among suburban municipalities, and 7.75 minutes (SD=1.09) among urban municipalities (H=69.39, p<.001). Rural municipalities had longer tone-to-en-route intervals than suburban municipalities (3.30 vs 2.05 minutes; U=2245.5, Holm-adjusted p<.001; rank-biserial correlation=0.50) and urban municipalities (3.30 vs 1.43 minutes; U=3530.5, adjusted p<.001; rank-biserial correlation=0.72). Rural en-route-to-scene intervals were likewise longer than those of suburban municipalities (8.95 vs 7.07 minutes; U=2208.5, adjusted p<.001; rank-biserial correlation=0.47) and urban municipalities (8.95 vs 6.54 minutes; U=3352.0, adjusted p<.001; rank-biserial correlation=0.64). Compared with urban municipalities, rural municipalities averaged 1.87 additional minutes between first tone and en route and 2.41 additional minutes between en route and scene arrival. Of the combined 4.28-minute difference across these two municipality-level component averages, 43.7% occurred during the tone-to-en-route interval and 56.3% during the en-route-to-scene interval. Conclusions: Rural Connecticut municipalities experienced longer EMS response intervals during both unit mobilization and travel to the emergency scene. Travel represented the larger descriptive share of the observed two-component rural–urban difference, although a substantial difference was already present before units became en route. These findings suggest that the contemporary rural EMS response-time disparity is distributed across more than one operational phase and may therefore require locally tailored strategies addressing both unit readiness and geographic deployment.