Abstract P124: Stroke Patient Transfer Destination is Influenced by Hospital Affiliation

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kori S Zachrison ◽  
Viviana Amati ◽  
Lee H Schwamm ◽  
Zhiyu Yan ◽  
Victoria Nielsen ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Patient Transfers ◽  
Network Characteristics ◽  
Event Modeling ◽  
Primary Object ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Hospital Affiliation ◽  
Hospital Characteristics

Background: Acute ischemic stroke (AIS) patients are frequently transferred between hospitals, however it is not clear whether these transfers are optimized with respect to proximity and quality of the destination hospital. Our primary object was to identify hospital characteristics associated with sending and receiving AIS patients. Methods: Using a comprehensive statewide dataset, we identified all AIS patient transfers occurring between all 78 Massachusetts (MA) hospitals from 2007 and 2015. Hospital variables included hospital quality reputation (US News & World Report), hospital capabilities (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliations (same vs. not). We also included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with patient transfers. This method decomposes events into a decision to transfer, and if so, the receiving hospital destination, and models them using a discrete-choice framework. Results: Among 73,114 AIS admissions in MA during the 8-year study period, there were 7,189 (9.8%) transfers. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital included teaching hospital status, hospitals of the same or higher quality, the same or higher stroke center status, and the same hospital affiliation (Table). Conclusion: Patients experiencing AIS in MA are frequently transferred between hospitals. After accounting for multiple relevant hospital characteristics, hospital affiliation remains an important factor in determining transfer destination. While there may be some benefits to hospital affiliation, stroke systems of care should be designed to maximize patient benefit and leverage interfacility transfer accordingly.

Abstract 1122‐000121: Integrated Geomapping Tool of Certified Stroke Centers in United States: A SVIN MT2020+ Committee Collaboration

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Evan Kolesnick ◽  
Evan Kolesnick ◽  
Alfredo Munoz ◽  
Kaiz Asif ◽  
Santiago Ortega‐Gutierrez ◽  
...  
Keyword(s):  
United States ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Healthcare Disparities ◽  
Systems Of Care ◽  
Stroke Care ◽  
The United States ◽  
Time Dependent ◽  
Stroke Systems Of Care ◽  
Stroke Center

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

Abstract W P286: Assessing Wisconsin Hospitals’ Capacity to Treat Acute Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Julie E Baumann
Keyword(s):  
Acute Stroke ◽  
Technical Assistance ◽  
Systems Of Care ◽  
Stroke Care ◽  
Self Report ◽  
The Status ◽  
Primary Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Reported Data

Introduction: Establishing regional stroke systems of care can improve timely treatment and survival, and reduce disability and related healthcare costs for persons experiencing acute stroke. A well-functioning stroke system requires seamless coordination between EMS, hospitals and certified stroke centers. Of 127 non-specialty hospitals in Wisconsin, 2% are comprehensive stroke centers and 24% have achieved primary stroke center certification. However, little is known about other hospitals’ capacity to treat acute stroke. The Wisconsin Stroke Coalition (WSC) wanted to better understand the need to improve stroke care capacity among hospitals not certified to treat stroke. The hypothesis was that few non-stroke certified hospitals in Wisconsin have all the criteria in place to treat acute stroke. Methods: WSC developed a short survey based on the Brain Attack Coalition’s recommendations for an acute stroke-ready hospital (ASRH). The tool included a user-friendly checklist that captured the status of each recommendation; in place currently or within six months; could be developed with assistance; or no plan to develop. WSC distributed the survey to 88 non-specialty, non-stroke certified hospitals and requested that each self-report their level of stroke care. Results: Fifty-nine percent of hospitals responded to the survey. Among respondents, 5% reported having all recommendations in place within six months, 53% reported having some of the recommendations in place and 1% reported no plan to develop any of the recommendations. While only a few had implemented every recommendation, the majority either had in place or were receptive to adopting individual suggestions. Nearly half of respondents reported having telestroke in place (either by phone, with video, or both). Conclusions: According to self-reported data, non-specialty, non-stroke certified hospitals in Wisconsin appear well-positioned or receptive to developing basic recommendations for acute stroke-ready hospitals. WSC plans to disseminate findings to Wisconsin hospitals and gather further information about technical assistance that would improve their level of stroke care and coordination with EMS.

Abstract WP340: Impact of Increasing Primary Stroke Center Transfers on Comprehensive Stroke Center Capacity

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jane Holl ◽  
Andy Cai ◽  
Lauren Ha ◽  
Alin Hulli ◽  
Melina Paan ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Vessel Occlusion ◽  
Capacity Limits ◽  
Transfer Rates ◽  
Primary Stroke Center ◽  
Comprehensive Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Occupancy Rates ◽  
Bed Occupancy Rates

Introduction: Given the time-sensitive benefits of acute stroke (AS) treatments, stroke systems of care must balance reducing door-in-door-out (DIDO) time at primary stroke centers (PSCs) with capacity limits at comprehensive stroke centers (CSCs). For example transferring more AS patients earlier in the process (e.g., prior vascular imaging for large vessel occlusion) from PSCs would result in more inappropriate transfers to CSCs that could overburden these centers.We conducted a simulation to estimate the balance between increased AS transfers from PSCs to CSCs and the percent of CSC time on “bypass” (inability to accept transfers to neuro-ICU). Methods: Clinicians from 3 Chicago-area CSCs and 3 affiliated PSCs and the Chicago Emergency Medical Services (EMS) created a PSC DIDO process map. We assumed CSC time on bypass is affected by AS and non-AS admissions from the CSC and from the affiliated PSCs. Input data were obtained fromtheChicago region registry (e.g., # PSC to CSC transfers), peer reviewed literature (US average transfer rate of AS patients to CSCs), EMS (PSC-CSC affiliations), and CSCs (e.g., average bed occupancy rates). CSC size was estimated by #neuro-ICU beds: small (12 beds), medium (23 beds), and large (28 beds). The simulation output was % time of CSC on “bypass”. Results: Table shows % time of CSC on bypass by varying PSC AS transfer rates for each category of CSC size. Larger increases in PSC transfer rates resulted in modest increases in CSC bypass rates, particularly for medium and large CSCs. Validation with data from one CSC showed < 4% overestimate of CSC % time on bypass. Conclusion: CSCs with more beds have efficiencies of scale leading to lower % time on bypass, even with increases in PSC AS transfer rates proportionate to CSC size. This model allows stroke systems of care to compute regional CSCs’ % time on bypass based on actual PSCs’ transfer rates and CSC size.

Abstract T MP54: Hospital Characteristics Associated with Advanced Primary Stroke Center Designation

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Catherine McDonald ◽  
Steven Cen ◽  
Lucas Ramirez ◽  
William J Mack ◽  
Nerses Sanossian
Keyword(s):  
Systems Of Care ◽  
Improve Patient Care ◽  
Federal State ◽  
National Guidelines ◽  
American Hospital ◽  
American Hospital Association ◽  
Community Provider ◽  
Primary Stroke Center ◽  
Stroke Center ◽  
Hospital Characteristics

Background: Organized stroke systems of care, including accreditation of hospitals as primary stroke centers (PSC), are meant to improve patient care and compliance with national guidelines. Nationwide, less than a third of eligible hospitals have achieved advanced certification in stroke. We aimed to characterize hospital factors associated with achievement of stroke center certification. Methods: We utilized the 2011 American Hospital Association survey to obtain data on hospital characteristics. Only hospitals with ≥ 25 beds and 24-hour emergency departments were evaluated. The Joint Commission (TJC), Healthcare Facilities Accreditation Program and DNV Healthcare websites were used to determine certification status of each hospital as a primary stroke center. All comprehensive SC were considered as PSC. Factors found to be associated with achievement of certification (P<0.010) were evaluated by logistic regression to determine a final model of independent association. Results: Of the 3696 hospitals to complete the survey, 3069 fulfilled study criteria, including 908 PSC (31%) and 2161 non-PSC. PSC were larger (mean 354 vs. 136 beds), had busier EDs (56,000 vs. 24,000 visits/year), were more often affiliated with ACGME residency programs (43% vs. 14%), AMA medical schools (51% vs. 21%), TJC-accreditation (95% vs. 65%), inpatient neurological services (94% vs. 46%) and trauma centers (55% VS 38%); and were less likely to be governmental (Federal/State/County 10% vs. 26%) and designated sole community provider (1% vs 9%). Independent hospital characteristics associated with PSC certification were TJC accreditation (OR 3.5, 95%CI 2.4-5.0), sole community provider (OR 0.22, 0.10-0.47), hospital type (governmental vs. non 0.61, 0.44-0.84), increasing size (per quartile in number of beds OR 2.5, 2.1-3.1) and neurological services (OR 3.2, 2.4-4.6). Conclusions: PSC hospitals are larger non-governmental hospitals with availability of neurological services. Increasing the low numbers of governmental (i.e. County or State) hospital achievement of PSC may be a potential area of focus.

Abstract TP365: Think Big: Weekly Stroke Education for Registered Nurses on the Stroke Unit

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Betty Robertson
Keyword(s):  
Systems Of Care ◽  
Stroke Care ◽  
Interesting Case ◽  
Stroke Patients ◽  
Stroke Units ◽  
Optimal Outcomes ◽  
Information Research ◽  
Stroke Education ◽  
Stroke Systems Of Care ◽  
Stroke Center

Background: Nurses play a pivotal role in all phases of care of the stroke patient. Stroke Nurses have responded to the challenge of making stroke systems of care a reality in recent years. We wanted our stroke nurses to use evidence-based practice to organize and deliver stroke services and facilitate optimal outcomes for stroke patients. One of the most important components of a Stroke Program is having a designated unit where patients receive specialized stroke care. Nurses who are a part of a stroke center should be trained to recognize medical complications that can arise in someone who has suffered a stroke. One of the most important reasons why primary stroke centers are the premier places for the treatment of strokes is that, by having specialized stroke units, patients have better outcomes. Is weekly stroke education for RNs on the stroke floor helpful to the nurses?<br Does it influence or impact the way they care for their patients? Methods: Since information,research and even nursing staff is always changing, education needs to be provided to nurses taking care of stroke patients so they have the latest and greatest knowledge to share with their patients and loved ones. We asked the staff what topic they wanted to cover and posted a suggestion box on the unit entitled “Ask a Stroke Nurse,” analyzed the attendance and did a survey to get the nurses’ feedback. Collectively we decided the best way to capture all staff on all shifts was to do weekly in-services and education sessions covering everything from Journal articles, updates about the program, interesting case studies, breaking science and even guest speakers from other departments. Conclusion: The survey showed that 96% of RNs on the stroke floor found the weekly education very valuable. 96% found that it positively impacted their practice,additionally, 91% said it greatly increased their knowledge about stroke & TIA. We will continue weekly education and continue to get feedback from the nurses. This endeavor has proven to be a very successful. We were pleased to see the positive comments from the staff about how much they enjoy and look forward to the classes each week.

Abstract TP244: A Successful Statewide Initiative to Designate Hospital as Remote Treatment Stroke Centers

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Shelley Nichols ◽  
Debbie Camp ◽  
McCord Smith ◽  
Chris Threlkeld ◽  
James Lugtu ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Systems Of Care ◽  
Standard Of Care ◽  
Stroke Care ◽  
Acute Stroke Care ◽  
Stroke Registry ◽  
Remote Treatment ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Iv Tpa

Background: As treatment of acute ischemic stroke (AIS) with IV tPA has become standard of care, smaller hospitals with limited resources have struggled to conform to consensus guidelines. To fill this practice gap, stroke systems of care were developed to support smaller, often rural, hospitals in providing standard stroke care to the patients they serve. Methods: As a result of legislative support from the Coverdell-Murphy Act, the Georgia Coverdell Acute Stroke Registry (GCASR) in collaboration with the Georgia Office of EMS (GA OEMS), the Georgia Hospital Association (GHA), and other state partners, developed a method for designating hospitals as Remote Treatment Stroke Centers (RTSC). The primary focus of performance improvement was treatment with IV tPA in eligible patients. Data collection and process change were used to improve the following quality indicators: percentage of eligible AIS patients treated with IV tPA and number of stroke alert notifications. Hospitals were required to partner with an accredited stroke center and use telemedicine to support the decision for administering IV tPA. GA OEMS was charged with reviewing and surveying individual hospitals applying for RTSC status. The GCASR served as the central repository to facilitate data sharing and benchmarking across hospitals. An inter-hospital transfer tool was created for EMS providers, adopted by GA OEMS, and disseminated throughout the state to guide management of patients receiving IV tPA who required transfer from a RTSC to an accredited stroke center. Results: Starting in 2014, pertinent information was distributed and assistance provided to the 24 RTSC eligible GCASR hospitals. At present, 4 hospitals have achieved designation; 1 hospital is pending survey; and several are considering application. In 2012-13 the now 4 RTSC hospitals gave IV tPA to 8 patients. In 2014-15 as these hospitals sought and achieved designation, this number rose to 24. During this same period, stroke alerts increased from 76 to 308. Conclusion: A state-based public health stroke initiative is effective in facilitating the designation of RTSC and thereby improving the delivery of acute stroke care in underserved areas.

Abstract WP296: Utilization of Advanced Imaging Paradigms Improves Patient Triage at Stroke Centers in a Stroke System of Care

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Karan Tarasaria ◽  
Syed Daniyal Asad ◽  
Dawn Beland ◽  
Amre Nouh ◽  
Mark J Alberts
Keyword(s):  
Time Window ◽  
Systems Of Care ◽  
Ct Perfusion ◽  
Final Diagnosis ◽  
Significant Advance ◽  
Advanced Imaging ◽  
Patient Transfers ◽  
Screening Algorithm ◽  
The Mean ◽  
Stroke Systems Of Care

Background: The 24 hour time window for endovascular therapy (EVT) in ischemic strokes due to large vessel occlusions (LVO) is a significant advance. Although many stroke systems of care have adopted a paradigm of transferring all potential EVT patients to the hub center for further evaluation, we developed an approach using advanced imaging at spoke hospitals to improve transfer triage. Hypothesis: Utilizing a novel algorithm combining clinical and imaging (CTA plus CT Perfusion “RAPID”) criteria at the spoke facilities results in more appropriate patient transfer decision to the CSC (hub). Methods: We developed and implemented a clinical and imaging screening algorithm for suspected LVO patients at our 3 PSCs and 1 CSC equipped with CTA and CTP-“RAPID” capabilities. Patients at the PSCs with NIHSS> 6 or fulfilling Stroke VAN (Hemiparesis and Visual field cut, aphasia or neglect) criteria and presenting within 24 hours from last seen normal undergo CTA plus CTP, and a decision for transfer if LVO plus core ≤50cc is met. Data including diagnosis, clinical and radiographic features, transfer status and final diagnosis of 377 patients from January 2018 to January 2019 were analyzed. Results: The mean age was 69 (SD 1.7) years and mean NIHSS was 11 (SD 0.79). Out of total 377 patients, 63% (n=236) were screened at PSCs and 37% (n=141) were screened at the CSC. About half (51%) of patients screened at PSCs (n=120) and 85% at the CSC (n=121) had a final diagnosis of acute ischemic stroke. Using our algorithm, 28% (n=65) patients were found to have LVO at PSCs compared to 60% (n=85) at the CSC. Only 23% (n=54) of patients were transferred to the CSC out of which 30% (n=16) underwent EVT. Among patients transferred to the CSC, 85% (n=46) had LVO, with the remaining 8 transferred for a higher level of care per. Almost half (49%) of the 116 patients screened at PSCs were stroke mimics, none of which were transferred. Conclusion: Using our new algorithm, 64% of screened patients were ischemic strokes and 40% had LVO’s, of whom 14% qualified for EVT. Using advanced clinical and imaging paradigms, 77% of screened patients did not require transfer. Utilization of CTP imaging at spoke PSCs is feasible and improves the accuracy and efficiency of patient transfers.

scholarly journals Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update

Stroke ◽  
2019 ◽  
Vol 50 (7) ◽  
Author(s):  
Opeolu Adeoye ◽  
Karin V. Nyström ◽  
Dileep R. Yavagal ◽  
Jean Luciano ◽  
Raul G. Nogueira ◽  
...  
Keyword(s):  
Neurocritical Care ◽  
Systems Of Care ◽  
Scientific Evidence ◽  
The United States ◽  
Public Healthcare ◽  
Policy Statement ◽  
Stroke Units ◽  
The Past ◽  
Stroke Systems Of Care ◽  
Stroke Center

In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.

scholarly journals Mechanical Thrombectomy-Ready Comprehensive Stroke Center Requirements and Endovascular Stroke Systems of Care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN)

2015 ◽  
Vol 4 (3-4) ◽  
pp. 138-150 ◽  
Author(s):  
Joey D. English ◽  
Dileep R. Yavagal ◽  
Rishi Gupta ◽  
Vallabh Janardhan ◽  
Osama O. Zaidat ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Endovascular Therapy ◽  
Mechanical Thrombectomy ◽  
Systems Of Care ◽  
Open Label ◽  
Comprehensive Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
New Evidence

Five landmark multicenter, prospective, randomized, open-label, blinded end point clinical trials have recently demonstrated significant clinical benefit of endovascular therapy with mechanical thrombectomy in acute ischemic stroke (AIS) patients presenting with proximal intracranial large vessel occlusions. The Society of Vascular and Interventional Neurology (SVIN) appointed an expert writing committee to summarize this new evidence and make recommendations on how these data should guide emergency endovascular therapy for AIS patients.

Abstract 185: Trends in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks Among Rural and Urban Medicare Beneficiaries, 2008-2017

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kori S Zachrison ◽  
Andrew D Wilcock ◽  
Lee H Schwamm ◽  
Lori Uscher-Pines ◽  
Jose R Zubizarreta ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Systems Of Care ◽  
Care Delivery ◽  
The United States ◽  
Medicare Beneficiaries ◽  
Rural And Urban ◽  
Using Data ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
First 90 Days

Introduction: Over the last decade substantial investments have been made in implementing stroke systems of care to improve access and quality of care. We sought to determine if these interventions have narrowed the rural-urban disparities in care over time for patients with acute stroke or transient ischemic attack (TIA). Methods: Descriptive observational study using data from all traditional Medicare beneficiaries in the United States from 2008-17 who presented to a hospital emergency department and were admitted either under observation stay or inpatient admission. Patients were classified as rural or urban based on home zip code. The main outcomes were rates of presentation to a certified stroke center, neurology consultation during admission, IV altepase, 90-day mortality, days living independently in the first 90 days post stroke, and 90-day spending. Results: We identified 3.31 million hospital stays for TIA and stroke in the study period. Rural and urban patients had similar age, race, gender, Medicaid status and presence of chronic conditions. In 2008, 24.4% and 60.4% of rural and urban patients respectively were cared for at a certified stroke center (disparity -36.1%). By 2017 this disparity had narrowed by 8.6% points (95% CI 6.6%,10.7%) (Fig). Between 2008 and 2017, the disparity in neurologist evaluation during admission narrowed by 7.4% (5.2%, 9.6%). However, there was no substantive change in disparity in alteplase use -0.1% (95% CI -0.5%,0.3%), mortality at 90 days 0.4% (95% CI 0.1%, 0.7%), or days living independently within 90 days -0.7 days (95% CI -1.1, 0.2). Spending in the first 90 days differentially increased among rural patients by $867 (95% CI 85, 1649). Conclusions: In the last decade, rural residents are more likely to receive care at a certified stroke center and receive neurologist consultation. However, disparities in outcomes are persistent, highlighting more work is needed to equitably extend stroke expertise to all Americans.

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