title: Stroke Legislation Impacts Distribution of Certified Stroke Centers in the United States.
abstract: OBJECTIVE
  The number of certified primary stroke centers (PSCs) have increased dramatically during the past decade in the United States We aimed to understand the factors affecting PSC distribution in the United States, including the impact of state stroke legislation.
  
  
  METHODS
  PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed.
  
  
  RESULTS
  By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia. The 18 states that had legislation in designating stroke centers and regulating stroke triage had higher PSC percentages (median, 43%; range, 13%-100%) than the remaining states (median, 13%; range, 4%-75%; P<0.001). State stroke legislation, urbanization, state economic output, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages when compared with the states without legislation (median increase, 16% versus 6%; P=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared with those certified by the Joint Commission (P<0.001).
  
  
  CONCLUSIONS
  State stroke legislation, a generalizable intervention, increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke.
authors.affiliation: From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH. uchinok@ccf.org.
authors.forename: Ken
authors.initials: K
authors.lastname: Uchino
authors.affiliation: From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH.
authors.forename: Shumei
authors.initials: S
authors.lastname: Man
authors.affiliation: From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH.
authors.forename: Jesse D
authors.initials: JD
authors.lastname: Schold
authors.affiliation: From the Cerebrovascular Center, Neurological Insitute (K.U., S.M., I.L.K.) and Department of Quantitative Health Sciences (J.D.S.), Cleveland Clinic, OH.
authors.forename: Irene L
authors.initials: IL
authors.lastname: Katzan
mesh_terms: D002568:Certification / Q000331:legislation & jurisprudence* / Q000592:standards; D006769:Hospitals, General / Q000331:legislation & jurisprudence* / Q000592:standards; D006801:Humans; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D014481:United States / Q000453:epidemiology
keywords: certification; geography; hospitals; stroke