Urban Sprawl and Delayed Ambulance Arrival in the U.S.


      Minimizing emergency medical service (EMS) response time is a central objective of prehospital care, yet the potential influence of built environment features such as urban sprawl on EMS system performance is often not considered.


      This study measures the association between urban sprawl and EMS response time to test the hypothesis that features of sprawling development increase the probability of delayed ambulance arrival.


      In 2008, EMS response times for 43,424 motor-vehicle crashes were obtained from the Fatal Analysis Reporting System, a national census of crashes involving ≥1 fatality. Sprawl at each crash location was measured using a continuous county-level index previously developed by Ewing et al. The association between sprawl and the probability of a delayed ambulance arrival (≥8 minutes) was then measured using generalized linear mixed modeling to account for correlation among crashes from the same county.


      Urban sprawl is significantly associated with increased EMS response time and a higher probability of delayed ambulance arrival (p=0.03). This probability increases quadratically as the severity of sprawl increases while controlling for nighttime crash occurrence, road conditions, and presence of construction. For example, in sprawling counties (e.g., Fayette County GA), the probability of a delayed ambulance arrival for daytime crashes in dry conditions without construction was 69% (95% CI=66%, 72%) compared with 31% (95% CI=28%, 35%) in counties with prominent smart-growth characteristics (e.g., Delaware County PA).


      Urban sprawl is significantly associated with increased EMS response time and a higher probability of delayed ambulance arrival following motor-vehicle crashes in the U.S. The results of this study suggest that promotion of community design and development that follows smart-growth principles and regulates urban sprawl may improve EMS performance and reliability.
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        • Frumkin H.
        • Frank L.
        • Jackson R.
        Urban sprawl and public health: designing, planning, and building for healthy communities.
        Island Press, Washington DC2004
        • Trowbridge M.J.
        • McDonald N.C.
        Urban sprawl and miles driven daily by teenagers in the United States.
        Am J Prev Med. 2008; 34: 202-206
        • Ewing R.
        • Pendall R.
        • Chen D.
        Measuring sprawl and its transportation impacts.
        Travel Demand Land Use. 2003; 1831: 175-183
        • Ewing R.
        • Schieber R.A.
        • Zegeer C.V.
        Urban sprawl as a risk factor in motor vehicle occupant and pedestrian fatalities.
        Am J Public Health. 2003; 93: 1541-1545
        • Myers J.B.
        • Slovis C.M.
        • Eckstein M.
        • et al.
        Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking.
        Prehosp Emerg Care. 2008; 12: 141-151
      1. National Center for Statistics and Analysis, National Highway Traffic Safety Administration. Fatal Analysis Reporting System (FARS);

        • National Highway Traffic Safety Administration
        2007 FARS coding and validation manual.
        U.S. Department of Transportation, Washington DC2007
        • Ewing R.
        • Brownson R.C.
        • Berrigan D.
        Relationship between urban sprawl and weight of United States youth.
        Am J Prev Med. 2006; 31: 464-474
        • Bailey E.D.
        • Sweeney T.
        Considerations in establishing emergency medical services response time goals.
        Prehosp Emerg Care. 2003; 7: 397-399
        • American Ambulance Association
        Contracting for emergency ambulances services.
        American Ambulance Association, Sacramento CA1994
        • Desai M.
        • Begg M.D.
        A comparison of regression approaches for analyzing clustered data.
        Am J Public Health. 2008; 98: 1425-1429
        • Vukmir R.
        The influence of urban, suburban, or rural locale on survival from refractory prehospital cardiac arrest.
        Am J Emerg Med. 2004; 22: 90-93
        • Lerner E.B.
        • Billittier A.J.
        • Sikora J.
        • Moscati R.
        Use of a geographic information system to determine appropriate means of trauma patient transport.
        Acad Emerg Med. 1999; 6: 1127-1133
        • Peleg K.
        • Pliskin J.S.
        A geographic information system simulation model of EMS: reducing ambulance response time.
        Am J Emerg Med. 2004; 22: 164-170
        • Millard W.B.
        Suburban sprawl: where does emergency medicine fit on the map?.
        Ann Emerg Med. 2007; 49: 71-74
        • Svenson J.E.
        Patterns of use of emergency medical transport: a population-based study.
        Am J Emerg Med. 2000; 18: 130-134
      2. Katz B, Bradley J. The suburban challenge. Newsweek 2009, Jan 26. Available from URL:

        • Lambert T.E.
        • Meyer P.B.
        Ex-urban sprawl as a factor in traffic fatalities and EMS response times in the Southeastern United States.
        J Econ Issues. 2006; XL: 941-953
        • Lambert T.E.
        • Meyer P.B.
        New and fringe residential development and emergency medical services response times in the United States.
        State Local Govert Rev. 2008; 40: 115-124
      3. Weiss E. In Va., vision of suburbia at a crossroads: targeting cul-de-sacs, rules now require through streets in new subdivisions. Washington Post 2009, Mar 22:A01.

      4. General Assembly of Virginia. Requirements for taking new streets into state secondary highway system. Virginia Acts of Assembly, 2007;Chap. 382(Sect. 33.1–70.3).