• Seth Seabury, Katalin Bognar, Yaping Xu, Caroline Huber, S Renee Commerford, and Darren Tayama.
• University of Southern California, Los Angeles, CA, United States. Electronic address: seabury@usc.edu.
• Am J Emerg Med. 2017 Sep 1; 35 (9): 1234-1239.

Background And PurposeThere is widespread geographic variation in healthcare quality, but we often lack clear strategies for improving quality in underserved areas. This study characterized geographic disparities in stroke care quality to assess whether improved access to neurological services has the potential to bridge the care quality gap, particularly in terms of alteplase (rt-PA) administration.MethodsThis was a retrospective study using quality performance data from the 2015 Hospital Compare database linked to information on certification status from the Joint Commission and information on local access to neurological services from the Area Health Resources File. We used these data to compare stroke care quality according to geographic area, certification, and neurologist access.ResultsNon-metropolitan hospitals performed worse than metropolitan hospitals on all assessed stroke care quality measures. The most prevalent disparity occurred in the use of rt-PA for eligible patients (52.2% versus 82.7%, respectively). Certified stroke centers in every geographic designation provided higher quality of care, whereas large variation was observed among non-certified hospitals. Regression analyses suggested that improvements in hospital certification or access to neurologists were associated with absolute improvements of 44.9% and 21.3%, respectively, in the percentage of patients receiving rt-PA.ConclusionsThe large quality gap in stroke care between metropolitan and non-metropolitan areas could be at least partly addressed through improved procedural efforts by stroke center certification increasing the supply of neurological services, (i.e. through training and hiring new neurologists) or by adopting decision support systems such as telemedicine.Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

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