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Objective To compare epidemiology, treatment pathways and outcomes for patients attended by emergency medical services (EMS) for atrial fibrillation (AF) and transported to public versus private hospitals within a universal healthcare system.Methods Population-based cohort study using linked ambulance, emergency department, hospital admission and mortality data in Victoria, Australia (January 2015 to June 2019). We included adult EMS attendances for AF with successful linkage and compared invasive cardiac procedures (coronary angiography, cardioversion and catheter ablation) during the index admission and follow-up as well as subsequent EMS reattendance and all-cause mortality using multilevel-adjusted regression models.Results Among 16 415 EMS attendances for AF, 14 526 (88%) were transported to public hospitals. Public hospital patients were older (median 78 vs 73 years) and more socioeconomically disadvantaged (24.5% vs 11.5% in the most disadvantaged quintile). The age-standardised incidence of EMS-transported AF was higher for public hospitals (121 vs 14 per 100 000 person-years). After adjustment, public hospital patients were less likely to undergo coronary angiography (adjusted OR (aOR) 0.29, 95% CI 0.23 to 0.36), catheter ablation (aOR 0.08, 95% CI 0.04 to 0.18) or cardioversion (aOR 0.47, 95% CI 0.36 to 0.63) during the index admission; disparities persisted during follow-up. Public hospital patients were more likely to have EMS reattendance within 30 days (adjusted HR (aHR) 1.56, 95% CI 1.09 to 2.24) but had lower adjusted long-term mortality over a median follow-up of 1.57 years (IQR 0.67 to 2.93; aHR 0.80, 95% CI 0.72 to 0.88).Conclusions In a universal healthcare system, hospital sector after EMS transport for AF was associated with substantial differences in procedural care and recurrent ambulance utilisation. These findings highlight sector-based variation in access to rhythm-control interventions and postdischarge pathways.