Impact of State Stroke Systems of Care Laws on Stroke Outcomes

Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003–2018), national stroke accreditation information (years 1997–2018), data from the Healthcare Cost and Utilization Project (years 2012–2018), and National Vital Statistics System (years 1979–2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610–1724 less per hospital stay), lower age-adjusted stroke mortality (1.0–1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6–5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality.