Race, Income, and Rurality Tied to Certified Stroke Centers in the US

Acute care hospitals in low-income, minority, and rural areas were less likely to receive stroke certification in the United States, according to an observational study published in JAMA Neurology.

Interventions for stroke have improved over the last two decades, but in the US, Black patients are less likely to receive advanced care. The Joint Commission in partnership with the American Heart Association began to standardize stroke care in 2004 by offering certification to hospitals, at their own expense. This study sought to evaluate systematic structural discrimination in access to quality stroke care among traditionally underserved communities.

Researchers with the National Bureau of Economic Research sourced data from stroke accreditation organizations the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, and Center for Improvement in Healthcare Quality. Between 2009 and 2019, hospitals with and without stroke certification were evaluated for rurality and the income level and ethnicity of the populations they serve.

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The hospitals (N=4984) served an average population of 300,824 (standard deviation [SD]603,995) individuals, 39% were rural, 17% were located in stroke belt states, 17% were for-profit hospitals, 40% had cardiac capacity, 26% were critical access hospitals, and 6% were teaching hospitals.

Stratified by type of certification, primary stroke centers increased from 961 to 1363, thrombectomy-capable stroke centers to 45, comprehensive stroke centers to 254, and acute stroke – ready hospitals to 101.

Stroke-certified hospitals were less likely to serve Black, racially segregated (adjusted hazard ratio [aHR], 0.74; 95% CI, 0.62-0.89) and tended to be less likely to serve Black, racially integrated (aHR, 0.85; 95% CI, 0.71-1.02) communities compared with non-Black, racially segregated populations; low income, economically segregated (aHR, 0.60; 95% CI, 0.50-0.71) and low income, economically integrated (aHR, 0.65; 95% CI, 0.55-0.77) communities. This was in comparison with high-income, economically segregated populations; rural areas (aHR, 0.38; 95% CI, 0.32-0.46) compared with urban areas. The stroke centers were also less likely to serve Hispanic, ethnically integrated populations (aHR, 0.86; 95% CI, 0.72-1.03) compared with non-Hispanic, ethnically segregated populations.

Hospitals were more than 3 times likely to adopt stroke care capacity if they served high-income, economically segregated (HR, 3.03; 95% CI, 1.59-5.56) or integrated (HR, 3.13; 95% CI, 1.64-5.88) communities .

Results were similar in sensitivity analyses.

This study may have included some errors, as there is not a central repository on data about stroke certification and data were sourced from various repositories in differing formats.

The researchers concluded that “Other literature has shown that stroke-certified hospitals provide higher-quality stroke care; our findings suggest that structural inequities in stroke care may be an important consideration in eliminating stroke disparities for vulnerable populations.”


Shen YC, Sarkar N, Hsia RY. Structural inequities for historically underserved communities in the adoption of stroke certification in the United States. JAMA Neurol. Published online June 27, 2022. doi:10.1001/jamaneurol.2022.1621

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