Editing: National Institute of Neurological Disorders and Stroke

www.ninds.nih.gov

Inequities in Access and 

Delivery of Acute Stroke Care

A Brain Attack Coalition Symposium Report

October 2022
Prepared by:

Office of Neuroscience Communications and Engagement

National Institute of Neurological Disorders and Stroke

National Institutes of Health

Department of Health and Human Services

For more information, please visit: www.ninds.nih.gov

October 2022

Suggested citation:

National Institutes of Health. National Institute of Neurological Disorders and Stroke. 2022. 

Inequities in Access and Delivery of Acute Stroke Care. Bethesda, MD: National Institutes of 

Health.
Contents

Preamble .......................................................................................................................................................................... i

Executive Summary................................................................................................................................................iii

1 Task Force Reports..............................................................................................................................................1

1.1 Prehospital Stroke Care.....................................................................................................................................1

Geography ...............................................................................................................................................................2

Policy and Regulation........................................................................................................................................3

Economics and Healthcare Resources.......................................................................................................5

Demographics........................................................................................................................................................7

1.2 Hyperacute and Acute Stroke Care............................................................................................................10

Geography ............................................................................................................................................................10

Policy and Regulation.....................................................................................................................................13

Economics and Healthcare Resources....................................................................................................14

Demographics.....................................................................................................................................................15

1.3 Inpatient Stroke Care......................................................................................................19

Geography ............................................................................................................................................................19

Policy and Regulation.....................................................................................................................................20

Economics and Healthcare Resources....................................................................................................21

Demographics.....................................................................................................................................................22

2 Action Opportunities........................................................................................................................................24

2.1 Prehospital Stroke Care.........................................................................................................................24

2.2 Hyperacute and Acute Stroke Care ..................................................................................................25

2.3 Inpatient Stroke Care..............................................................................................................................26

3 Conclusion...............................................................................................................................................................27

References...................................................................................................................................................................29

Appendix A: Brain Attack Coalition Symposium Agenda and Recordings..........................40

Appendix B: Telemedicine in Stroke Care...............................................................................................43

Appendix C: Steering Committee and Task Force Members........................................................46

Appendix D: Acronyms and Abbreviations.............................................................................................52

Appendix E: Acknowledgements...................................................................................................................55
i 

Preamble 

Mark J. Alberts, M.D.

Brain Attack Coalition Chair and Symposium Steering Committee Co-Chair

Stroke is a leading cause of death and disability in the United States, affecting more than 795,000 

individuals annually (Tsao et al., 2022). Additional patients have some form of cerebrovascular 

disease or transient ischemic attack. Each year, hospitals and healthcare systems across the country

provide lifesaving stroke treatments to thousands of people, but many more do not receive timely 

and adequate stroke care. Hidden within these statistics are racial, ethnic, socioeconomic, and 

geographic inequities in stroke care that continue to impact the U.S. healthcare system, our 

patients, and their families. Considering the incidence and prevalence of stroke—as well as the 

importance of aging on stroke occurrence—these disparities will have an increasing impact on 

public health in the coming years and decades.

Recognizing this as a growing problem, on March 17-18, 2022, the National Institute of 

Neurological Disorders and Stroke (NINDS) sponsored a symposium of the Brain Attack Coalition

titled Inequities in Access and Delivery of Acute Stroke Care. The call to action for the symposium was 

to leverage current knowledge, approaches, and technologies to better understand the etiologies 

for the various disparities. The ultimate goal was toformulate strategies and specific interventions 

to mitigate such inequities, thus, improving patient care and clinical outcomes for all populations.

The first goal of the symposium was to define the current scope of inequities in acute stroke care 

and understand their root causes and major contributors. We examined these issues through the 

prism of three major time epochs: prehospital care, acute care in an emergency department setting, 

and in-hospital or inpatient care. Other stroke care epochs such as primordial care, primary 

prevention, and post-stroke rehabilitation are of obvious importance but were beyond the purview 

of the symposium. However, these considerations were included in our formulations and 

recommendationswhenever possible. 

For all time epochs, we examined four cross-cutting themes: geography, policy and regulatory 

issues, economics and healthcare resources, and demographics. The importance of each theme 

varied depending on the time epoch and care paradigm. We further refinedand focused each 

element based on information gathered during the symposium. Our hope is that hospitals, health 

systems, payors, and medical professionalswill find these reports useful in service to the patient 

community.

Prehospital care was a key focus of the symposium because deficiencies in early recognition, triage, 

and transport have clear downstream implications in terms of treatment options, care venues, and 

clinical outcomes. Limited prehospital care and emergency medical resources are common sources 

of inequity in many cities and regions. Regarding the acute care epoch (both emergency and inhospital care), sources of disparity may relate to differences in hospital capabilities, such as staffing, 

infrastructure, and related resources. We identified several barriers to stroke care, some of which 

were thought to be artificial based on the hospital, the system, and/or provider network concerns. 

Other barriers were state-based issues, potentiallydriven by state policies, rules and regulations, 
ii

and/or financial concerns. Some of these issues are largely driven or defined by insurance issues 

and limitations.

Socioeconomic status has often been cited as underlying many inequities in healthcare that exist 

today. Gaining a better understanding of the role of socioeconomic differences across the stroke 

care continuum (at the individual and population level) might inform us about the best approaches 

to address such disparities.

Further, when discussing stroke etiology, it is important to understand and acknowledge the 

diversity of affected populations, as well as the risk factors that lead to stroke. The heterogeneous 

nature of stroke mandates approaches that account for the variable impact of environmental 

factors, acquired risk factors, and genetic influences, all of which contribute to the development of 

ischemic stroke, hemorrhagic stroke, and cerebrovascular disease.

The good news is that we can resolve many of these concerns and disparities. As a first step, we 

could leverage tools and technologies and potentially modify stroke care policy. Some disparities 

may require fundamental alterations by way of reallocating resources, while others may require 

major alterations in the delivery of stroke care and implementation of these changes at a national 

level. Enhancing the diversity of stroke leadership committees who formulate policy and stroke 

care guidelines may help address the lack of diversity in the stroke care workforce and improve 

equity.

Clearly defining areas where there is a lack of diversity and equity, as well as developing a better 

understanding of their root causes, is a necessary process to begin to formulate timely and effective 

interventions to address and solve today’s disparities. We understand that in some cases, a 

common solution or approach might be able to address multiple concerns, perhaps in multiple 

geographic regions or care venues. Other cases may require more specific and targeted 

interventions.

Stroke is too common a problem and a major public health concern—we simply must do a better 

job addressing disparities along the entire continuum of care for patients and families. It is 

important to acknowledge that inequities exist in almost all aspects of stroke care, including 

primary prevention, acute care, post-stroke care, and outcomes.Having said that, due to limitations 

in time and resources, we had to begin our efforts within a reasonable time epoch.

We believe that starting in the acute care arena provides a feasible opportunity to identify common 

and significant issues that, when properly addressed, will have a good chance of eliminating 

disparities in care that will result in improved outcomes within a relatively short time frame, while 

also using available resources. The reports that follow, informed by task forces of stroke experts 

and proceedings of the symposium, provide additional context for each time epoch, including shortand long-term actionable goals.
iii

Executive Summary

Prior to the Brain Attack Coalition’s Inequities in Access and Delivery of Acute Stroke Care

symposium, the National Institute of Neurological Disorders and Stroke (NINDS), as a member of 

the Brain Attack Coalition, orchestrated a series of steering committee, task force, and subgroup 

meetings to begin thoughtful discussions on inequities in stroke care and possible strategies to 

address them. 

During the meetings, task force members identified key disparities in stroke care and their root 

causes, potential solutions, best practices, remaining knowledge or research gaps, and tangible 

actions over both the short- and long-term to address inequities. Notably, each task force was 

composed of diverse, multidisciplinary teams of stroke and public health experts, including 

neurologists, emergency specialists, epidemiologists, health policy analysts, professional group 

representatives, and others,whovoluntarily came together to formulate these recommendations 

on how to improve equity in stroke care.

Findings from each task force were formally presented at the public symposium, where they were 

cumulatively reviewed, re-evaluated, and discussed further among task force members, the steering 

committee, and attendees. We are grateful that individuals from different professions, medical 

specialties, and parts of the nation participated in the symposium, providing us with invaluable 

insight and feedback on our proposed reports.Although extensively detailed in the proceeding 

chapters, the key findings and recommendations of each task force can be summarized as follows:

Prehospital Stroke Care

In the prehospital care setting, there are many disparities in quantity, distance, and availability of 

emergency medical services (EMS), especially in rural areas of the country. For a variety of reasons, 

there are also disparities in awareness of stroke signs and symptoms among prehospital providers 

and the public, and underutilization of 911 and/or EMS by persons in minority and underserved 

populations. To better understand and address these disparities, the task force recommends:

• Regionalization of prehospital stroke systems of care would remove artificial and regulatory 

barriers to receiving high-quality stroke care. Nationally, the establishment of prehospital

standards of care and related metrics could improve care for all populations—particularly

people of color.

• Because EMS in the U.S. is largely regulated at the state and local level, leadership in the 

stroke field should work with their state and local regulators to assess education gaps and

training needs among prehospital care providers.

• Expanding and enhancing successful culturally sensitive, sustainable stroke recognition

public health campaigns could encourage broader EMS use. Also, prehospital 

reimbursement models should be modified to reduce costs for patients and better align

with their needs.

• Diversity in the EMS workforce, including dispatchers, paramedics, and others along the 

chain of survival, is lacking. Establishing diversity committees and officers, networking
iv

opportunities, recruitment/retention programs, removing financial barriers, and other 

efforts could enhance the diversity of EMS and the entire stroke workforce.

• Recognizing the success of telemedicine (telestroke)in the hyperacute and acute care 

setting, telestroke services need to expand into EMS and prehospital stroke care.

Hyperacute and Acute Stroke Care

In the hyperacute and acute care setting—the moments just before hospital arrival until definite 

hospital admission—there are clear inequities in access to high-level stroke centers. Many 

providers lack sufficient educational resources to maintain expertise and engage with diverse 

patient populations. There is also limited access to and inconsistent use of telemedicine, and low 

research study participation by hospitals and patients, particularly in rural settings. To understand 

and address these issues, the task force recommends:

• Developing a student loan repayment program for stroke neurologists and

interventionalists could enhance employment and practice. This could ensure that lowerresourced hospitals achieve higher levels of stroke certification, thereby improving access 

to stroke expertise.

• Incorporating Mobile Interventional Stroke Team (MIST) models could improve access to 

thrombectomy and reduce hospital transfers, particularly outside of urban settings.

• Improvement, standardization, and expansion of educational resources and support to 

providers could ensure sufficient stroke expertise. 

• Telestroke is a key component of acute stroke services, particularly in hospitals with limited 

access to experienced stroke physicians. There is a need for uniform licensing and national

and/or state-wide guidelines, better infrastructure, and training in telemedicine adaptation.

Inpatient Stroke Care

In the inpatient setting,there are disparities in the use of validated and proven secondary stroke 

prevention measures and therapies. There are also disparities in the availability of rehabilitation 

services and other resources to help patients transition from inpatient to outpatient care. To better 

understand and address disparities, the task force recommends:

• Additional research is neededto better describe disparities in inpatient secondary stroke 

prevention measures (e.g., implanted cardiac monitors, antithrombotic drugs, statins) and

medication prescribing at discharge. Studies should focus on evaluating: 1) ethnicity/race

and geography interaction; and 2) patient education, income levels, and health insurance 

coverage.

• Research is needed to determine how best to facilitate the community navigation necessary 

to encourage positive health outcomes for individuals transitioning back into rural and

other low-resourced communities.

• Significant gaps in knowledge about disparities in inpatient care can be addressed by 

standardizing terminology and categories. For example, by requiring the use of NINDS

Common Data Elements in research publications. There is also a need to improve the 

definitions of patient-level (e.g., non-adherence), provider-level (e.g., risk

assessment/benefit), and societal-level (e.g., drug costs)factors.
v 

• Additional research is needed to assess which characteristics of rurality and other

demographics are most salient to the inpatient and post-stroke care experience.

This summary serves to highlight the main findings and recommendations discussed in the 

following chapters. While the task force reports uncover numerous prominent disparities in acute 

stroke care, many remain unknown. Among other opportunities, developing a regional or national 

stroke registry could provide important insights into disparities across the entire stroke system of 

care, nationwide, eventually improving outcomes for all. The stroke community should seize these 

opportunities in the short- and long-term, working together to implement feasible solutions that 

address known inequities in access to stroke care, to the benefit of our most at-risk populations.
1 

Task Force Reports

Prehospital Stroke Care

Stroke is a leading cause of death and long-term disability in the United States, reaching about 

795,000 victims annually (Centers for Disease Control andPrevention. Underlying Cause of Death, 

1999-2020, 2020). For each minute of a stroke, about 1.9 million neurons die (Saver, 2006). Acute 

treatments such as intravenous tissue-type plasminogen activator (IV tPA)—also called alteplase 

(Activase®)—and endovascular thrombectomy (EVT) may improve patient outcomes when 

administered early, during symptom onset (Powers et al., 2019). As a result, time-sensitive, highquality care is needed to support patients at the earliest signs of stroke.

Over a decade ago, the National Academy of Medicine (formerly the Institute of Medicine) identified 

that evidence-based care was significantly more limited in the prehospital setting than it was in 

other areas of medicine (Institute of Medicine, 2007). A systematic review of prehospital evidencebased guidelines published prior to 2019 found that most guidelines written for prehospital care 

were not developed or written in a way that would be considered high quality by standards put 

forth by the National Academy of Medicine or by the Appraisal of Guidelines Research and 

Evaluation Trust(Turner et al., 2021). Subsequently, a Delphi process of experts in prehospital 

medicine and guideline development identified acute stroke management as a priority for evidencebased guideline development(Richards et al., 2022). 

The prehospital stroke setting includes family and community members, emergency medical 

service (EMS) professionals, aswell as the systems, structures, and policies that shape the stroke 

care environment. In the community, after it is recognized that a person is having a stroke, 911 

should be called immediately. EMS plays a significant role in stroke chain of survival—being the 

first medical personnel on-scene, they stabilize the patient to quickly identify a stroke, gather 

information about when the patient was last known to be well, transport the patient to the hospital 

with the best level of care for stroke severity and timing, and pre-notify hospital teams of a stroke 

arrival(Acker III et al., 2007). Prenotification triggers the activation of stroke teams in the 

emergency department and clearance of neuroimaging machines, avoiding triage delays and 

decreasing wait times (Abboud et al., 2016; Abdullah et al., 2008; Ashcraft et al., 2021; Kim et al., 

2009; Lin et al., 2012). Although most patients can rapidly access stroke centers on their own, about 

50-60% of stroke patients arrive to the hospital by EMS (Asaithambi et al., 2021; Govindarajan et

al., 2013; Tataris et al., 2014; Zachrison et al., 2022).

Time from symptom onset (i.e., when the patient was last known well) to treatment is a strong 

predictor of return to functional independence; thus, prehospital factors that shorten time to 

treatment are critical to stroke survival and mitigation of long-term disability (Hacke, 2004; Jahan 

et al., 2019; Marler et al., 2000). It is well known that that arrival by EMS is associated with more 

rapid door-to-imaging times, shorter door-to-needle times, and more frequent use of IV alteplase 

(Abdullah et al., 2008). However, only 25-30% of acute ischemic stroke patients arrive within the 

recommended treatment windows, and studies have shown that patients arriving by EMS are more 

likely to arrive within the treatment window than those arriving by personal transport (Mochari-
2 

Greenberger et al., 2015; Tong et al., 2012). Several sociodemographic disparities in EMS use are 

inversely associated with timely treatment of stroke, including female sex, being from a minority 

racial/ethnic group, and rurality (Ader et al., 2019; Boehme et al., 2014; Springer et al., 2017). 

Inpatient surveys suggest that some symptoms of stroke may go unrecognized by stroke patients 

and their family members, and that family members may incorrectly advise stroke victims that EMS 

use is not necessary (Eisenstein et al., 2018; Xirasagar et al., 2019). 

Geography

Geographic disparities in prehospital stroke care include variability in quality, access, and 

experience with stroke dispatch, EMS infrastructure, and prehospital provider training and 

experience. Many of these disparities are exacerbated in rural areas of the country, but also exist in 

suburban and urban areas, as well as within U.S. territories and native peoples’ reservations 

(Adeoye et al., 2019; Georgakakos et al., 2022; Harrington et al., 2020; Jauch et al., 2021; Mullen et 

al., 2014; Salwi et al., 2021; Yu et al., 2021). The rapid introduction of EVT has highlighted 

disparities in access regarding prehospital triage and interfacility transport, as well as variability in 

the use of large vessel occlusion (LVO) scales.Access to aeromedical transport, prehospital 

telemedicine, and mobile stroke units depend on the specific needs, size, and rurality of the 

location.Geographic disparities in prehospital stroke care also introduce logistical concerns for 

routing, traffic, and physical barriers to facility-based triage. Cultural differences in EMS provider 

groups and patient populations further contribute to disparities in access to stroke care. 

Regionalization of prehospital stroke care

Geographic stroke systems of care should consider quantity, distance, and availability of ambulance 

agencies, fire and rescue, aeromedical, and interfacility transport. A systems-based approach to 

prehospital stroke care requires collaboration between state and local government policymakers, 

regional health systems, local hospitals, and area ambulance agencies. Critically, regionalized stroke 

networks must overcome market competitiveness and share the responsibility of developing 

regional standardization of prehospital stroke screening, routing protocols, and EMS training and 

education. To help support regionalization of prehospital stroke care, stroke systems should 

incorporate acute stroke ready, primary, thrombectomy-capable, and comprehensive stroke 

centers in a geographically mindful way that facilitates collaboration rather than competition in 

stroke triage (Jauch et al., 2021). 

Mobile stroke units have been shown to reduce treatment times and improve outcomes (Ebinger et 

al., 2021; Grotta et al., 2021). However, longitudinal studies on cost effectiveness are needed to 

inform the generalizability and regional impact of mobile stroke units, particularly in rural and 

resource-limited settings. 

Stroke recognition among prehospital providers and the public

Inherent in addressing geographic disparities in acute stroke care is ensuring that all first 

responders across the prehospital continuum—including dispatch, EMS practitioners, fire and 

rescue, and police—can accurately identify stroke, especially those in underserved areas (e.g., rural, 

U.S. territories). In addition, other factors often driven by geographical disparities, such as 
3 

socioeconomic status, cultural differences, and local governance and policies, contribute to a 

diverse makeup of the prehospital provider population and differences in stroke awareness in the 

local community. Collectively, these factors have a significant impact on patient access to acute 

stroke care (Adeoye et al., 2014; Adeoye et al., 2019; Rivard et al., 2021; Salwi et al., 2021; Yu et al., 

2021). 

Leaders must work with state and local regulators to improve education and resources for stroke 

education and training among prehospital providers. Training and education should be culturally 

tailored and consistent with state and local stroke protocols. Additionally, statewide efforts should 

standardize training and application of prehospital stroke screening scales, including advocating for 

the standardized use of LVO scales to aid in the appropriate triage of patients to thrombectomycapable and comprehensive stroke centers. 

Telestroke in the prehospital setting

While telestroke systems are currently designed to address geographic disparities in hospital-based 

acute stroke care, they are also relevant to EMS and prehospital stroke care, particularly when 

telemedicine is used to facilitate ambulance-based assessment. Several studies have demonstrated 

the feasibility of using low-cost telemedicine in prehospital neurologic assessments and decisionsupport for acute stroke triage, which was particularly applicable in regions with longer transport 

times and a less experienced EMS workforce (Guzik et al., 2021; Lippman et al., 2016; Smith et al., 

2016). Further, ambulance-based telestroke is essential to the potential cost utility of mobile stroke 

units (Southerland & Brandler, 2017; Wu et al., 2017). 

Similar to advocacy for hospital-based acute stroke care, we need to work with policymakers, 

payers, and technology suppliers regarding reimbursement, availability of broadband, and wireless 

infrastructure for telestroke and other promising prehospital digital health systems. See Appendix 

B: Telemedicine in Stroke Carefor more findings and recommendations regardingtelestroke.

Policy and Regulation

In the U.S., EMS are largely regulated at the state and local levels. While federal entities, such as the 

National Highway and Transportation Safety Administration, the Federal Interagency Committee on 

Emergency Medical Services, and the National EMS Advisory Council, typically provide guidance 

and coordination among regional entities, most direct regulation occurs locally. For example, EMS 

practitioner and EMS agency certification and regulation occurs at the state level and medical 

protocols—including stroke protocols—are determined locally. 

In some instances, EMS protocols are determined regionally or state-wide, but this model is much 

less common. The National Association of State EMS Officials, a nationwide network of state, 

regional, and local EMS and emergency care systems, regularly publishes model EMS clinical 

guidelines, but these recommendations serve as a guide and resource; there is no mandate to 

incorporate any of the model clinical guidelines into operational protocols at the EMS agency level

(Cash et al., 2020). 

Local determination of EMS protocols can be advantageous because this ensures that protocols are 

adaptable to local EMS system of care capabilities (i.e., hospital resources, EMS provider agency 
4 

considerations, local geography, etc.), however, there is variability among EMS provider agencies, 

which may contribute to significant disparities in stroke care. Regardingstroke and trauma, 

advocacy with state legislatures and state health departments has resulted in some states adopting 

state-wide required components of EMS care (e.g., severe stroke screening) where none previously 

existed; but without coordinated policies, fragmentation will continue to exist.

Modification of prehospital reimbursement models

While regulation of EMS is local, reimbursement of prehospital care falls under the Centers for 

Medicare and Medicaid Services (CMS) fee schedule for ambulance transport (Ambulance Fee 

Schedule Public Use Files, 2022). First, a requisite component of ambulance transport 

reimbursement is the transport of a patient. For most patients with suspected acute stroke, 

transportation is a component of care, but extensive decision-making resulting in a patient refusing 

ambulance transport is not reimbursable. 

Next and most important, the base reimbursement level is determined by a general estimate of the 

complexity of care provided on scene, which is determined by whether the patient required an 

assessment by an advanced life support (ALS) practitioner (i.e., paramedic) or not. However, this 

complexity of care is more reflective of a patient with hemodynamic instability, rather than acute 

neurological dysfunction. 

For example, a lower level of reimbursement, known as ALS-1, requires an ALS assessment and one 

intervention that only an ALS practitioner can perform (for example, a peripheral intravenous 

catheter placement). The highest level of ALS reimbursement, known as ALS-2, requires the 

administration of three or more medications and the performance of an advanced procedure (e.g., 

defibrillation, endotracheal intubation, cardiac pacing). These interventions are typically done for 

hemodynamically unstable patients but not acute stroke patients. Although the recognition and 

management of acute stroke is critically important to overall stroke care, acute stroke patients 

typically do not have the hemodynamic instability that indicates a higher level of reimbursement. 

Therefore, the complexity of assessment and destination decision-making involved in prehospital 

stroke care are not appropriately reflected in the metrics used to determine reimbursement for 

prehospital services. 

Lastly, reimbursement is multiplied based on the mileage traveled with the patient and the rurality 

or urbanicity of the site of patient transport. Therefore, in acute stroke and other time sensitive 

conditions that require complex assessment and decision-making by EMS practitioners, 

reimbursement models do not reflect the complexity of care provided. 

Current models of reimbursable patient-centered care

In 2020, the CMS launched the Emergency Triage, Treat, and Transport (ET3) Model pilot program

to expand reimbursable patient-centered care (Goldman et al., 2020). The goal of this pilot is to 

explore alternate models of prehospital care, including transport to non-hospital destinations, such 

as primary care offices and community mental health centers. The program also aims to explore 

reimbursement of extensive on-scene evaluation that would obviate a potential ambulance 

transport (i.e., through telehealth). The primary goal of the ET3 model is to reduce the cost of 

healthcare by reducing EMS transport of patients to hospital emergency departments. 
5 

Additionally, the National EMS Quality Alliance strives to codify quality metrics for prehospital care 

that reflect how well care is provided instead of relying on procedure-based and transport distance 

compensation. For acute stroke patients, current metrics are modest and report the rate of stroke 

screens performed on suspected stroke patients and the recording of glucose readings. 

Unfortunately, rather than rewarding the complex care that acute stroke patients need, current

EMS models focus on avoiding costly services. New initiatives are starting to acknowledge the 

complex care that can be provided by EMS practitioners before hospital arrival. However, given the 

pilot and limited nature of both initiatives, acute stroke patient care cannot improvewithout 

further development. For example, performing an advanced stroke severity screen to determine 

transport to a higher-level stroke center is not captured in current models as a critical prehospital 

intervention.

Linking prehospital care and patient outcomes

Historically, in acute stroke, the link between the care provided in the prehospital setting and 

patient outcomes during hospitalization and beyond remains unclear. A critically important 

logistical barrier is the lack of integration between prehospital patient care and hospital patient 

care reports. From a hospital’s point of view, all care provided prior to hospital arrival is often a 

“black box”, even if the patient received significantly important assessments and interventions

(Mears, Pratt, et al., 2010; Mears, Rosamond, et al., 2010; Powers, 2015). Similarly, for EMS 

practitioners, the eventual outcome of the patient’s course in the hospital is difficult or impossible 

to routinely ascertain or track, which means that quality improvement initiatives are largely 

informed by operational metrics and not by patient-oriented outcomes (Cash et al., 2017). 

Several initiatives have begun to link prehospital records to hospital records. For example, in recent 

years, the Paul Coverdell National Acute Stroke Program (Coverdell Program) has facilitated these 

record linkages, with a focus on acute stroke. In the private sector, the patient care software 

company ESO Solutions, Inc. hosts the ESO Data Collaborative, one of the largest prehospital 

research databases in the country. This comprehensive database links EMS records to hospitalbased records and patient outcomes (Crowe et al., 2021; Fernandez et al., 2020; Jarvis et al., 2020; 

Walter et al., 2021). 

Lastly, there are several research programs dedicated to determining how prehospital care 

contributes to overall patient outcomes (Audebert et al., 2017; Helwig et al., 2019; Itrat et al., 2016). 

While these initial programs have improved communication between prehospital and hospital 

stages of care of acute stroke patients, routine and universal linkage is far from a reality. Although 

substantial opportunity exists to align payment through the CMS with the National EMS 

Information System (NEMSIS), current NEMSIS data are de-identified and not connected to claims 

or hospital data.

Economics and Healthcare Resources

The intersection of economic and healthcare resources in prehospital stroke care is complex. EMS 

regulation typically occurs at the state, territory, or local level, whereas stroke standards of care are 

created by professional organizations, and payment is driven by state (i.e., Medicaid), federal (i.e., 
6 

Medicare), and private (i.e., the insurance industry) sources. Prehospital and hospital-based stroke 

care systems are highly interdependent and reflectthe communities that they serve. Although 

exceptions exist where legacy referral hospitals, often academic medical centers, thrive in 

economically challenged communities, a community’s economy often determines the quality of 

healthcare resources available(Merwin et al., 2006). Disparities in health outcomes are associated 

with variability in regional resource availability. These disparities primarily impact racial and 

ethnic minority groups, people living in rural areas, and those with who are economically 

disadvantaged.

Stroke and the broader emergency critical care system

Prehospital care is a central touchpoint between the community and the healthcare system for 

patients with acute stroke and other emergency conditions. To date, however, efforts to improve 

out-of-hospital care for patients with stroke are not part of efforts focused on other conditions, 

including trauma, ST-elevation myocardial infarction (STEMI), and out-of-hospital cardiac arrest. 

The National Quality Forum (NQF) recently described the importance of using multidisciplinary 

coordination to improve outcomes for critical illness and injury (National Quality Forum, 2021). By 

developing a model that allows for shared accountability for health outcomes (attribution) at the 

community level, key stakeholders including hospitals, health departments, and prehospital 

providers, would have aligned incentives to work together to improve access to care and optimize 

outcomes for the communities that they serve. 

While most prehospital care is organized at the community level, healthcare is primarily focused on 

individual patient care. The geographic and community approach ofthis report represents a 

framing that is gaining traction around healthcare planning, which includes trauma, STEMI, 

regional preparedness, cardiac arrest care, and stroke. This framework, now captured in the NQF’s 

work described above, lays the foundation for a connection between population-based planning 

and population-based payment or incentive structures. National legislation could create a pathway 

from measurement to implementation of best practices, mandate public reporting of variability in 

regional resources (especially in healthcare deserts), create guidance on how to risk adjust health 

outcomes based on regional healthcare resources, and direct an investment in delivery system 

science focused on improving our understanding of how the underlying economic drivers of 

healthcare resource allocation impact disparities in health outcomes. 

Developing a national stroke registry

The lack of a national stroke registry not only limits our ability to inform clinical practice, but also 

introduces economic bias into stroke care research. This is because more highly resourced stroke 

and referral centers are more inclined to participate in voluntary registries. Research on the 

availability and quality of healthcare resources are particularly lacking for minority populations, 

including in U.S. territories and Native American populations. The lack of representative data limits 

the ability to develop meaningful metrics to inform national policies and standards around valuebased reimbursement, EMS protocols, patient transport, stroke center performance, mobile stroke 

unit access, telestroke utilization, and the regionalization of prehospital stroke care across states 

and territories. Establishment of a national stroke registry would provide realtime data on the care 
7 

delivered to stroke patients and enable shared visibility of the costs, reimbursements, management, 

and outcomes of stroke care before and after acute treatment. 

Demographics

Among other disparities, it is well known that racial, ethnic, and sex differences exist regarding the 

utilization of EMS transport among hospitalized stroke patients (Mochari-Greenberger et al., 2015). 

Derived from multiple community and other prehospital related factors, there is a downstream 

effect contributing to the observed demographic disparities seen in stroke treatment rates related 

to sex/gender, race, ethnicity, socioeconomic status, and insurance status, with certain populations 

having lower acute phase treatment rates compared to baseline (Hsia et al., 2011; Schwamm et al., 

2010). 

Priority areas of focus to reduce health disparities in the prehospital stroke setting include: (1) the 

development of a high-quality, systematic and comprehensive national data collection, which may 

be used at the community level to expand the current evidence base and provide the information 

necessary for potential targeted interventions; (2) an expansion of programs, practices, and 

procedures to enhance public education about stroke identification and acute management, 

especially for populations and/or regions in which disparities exist; and (3) to broadly expand, 

where necessary, requisite EMS systems health equity training and workforce diversity.

Collecting high-quality, systemic national data

For stroke systems of care, the collection of high-quality, systematic, comprehensive and 

measurable data, at both a community and national level, is essential to evaluate current 

performance, identify areas of improvement, and to examine the effects of continuous quality 

improvement programs (Rudd et al., 2020). Such data can have an integral role in identifying and 

evaluating demographical health disparities of key prehospital variables, such as the identification 

of stroke symptoms by bystanders and EMS, 911 utilization rates, EMS dispatch effectiveness, onscene time, accessibility to care, and linking such items to national averages, as well as hospitalbased outcomes including treatment rates, overall morbidity and mortality. In turn, analyzing 

registry data, at a regional or statewide level, may lead to the identification of demographical 

disparities, providing opportunities for targeted interventions aimed at standardizing care 

outcomes for all. 

Today, several platforms exist, and software designed to connect prehospital and health system 

data is being developed. At a state level, the Centers for Disease Control and Prevention (CDC) has 

supported the development of stroke registries (Group, 2005; Wattigney et al., 2003), but they are 

not uniformly existent in most states. The American Heart Association and other nonprofit 

organizations have created national databases, currently accounting for the most robust national 

level prehospital demographical stroke database (i.e., the Get With The Guidelines Stroke Program) 

(Schwamm, Fonarow, et al., 2009). However, these “super-user” type platforms designed to collect, 

collate, and analyze state and community level data are only utilized at participating stroke centers 

and at a limited number of state health departments.

Proposed solutions include: 
8 

• Advocate for the more widespread creation of state and/or regional stroke registries, which 

may complement and enhance existing national registries.

• Advocate for state health departments to devote funding, resources, and staff to collecting 

and interpreting state level stroke registry data.

• Support further enhancement of gathering key prehospital metrics and link them to 

demographical variables and health center outcome data.

• Enhance collection and utilization of high-quality data to provide the basis-ofunderstanding necessary to inform targeted interventions aimed at reducing demographical 

disparities in prehospital care.

Public education about stroke

Age, sex and gender, and racial/ethnicdisparities exist in the placement of 911 calls and 

subsequent EMS utilization.Demographical differences also occur in the prehospital identification 

of stroke, both by bystanders and EMS providers (Govindarajan et al., 2015). The reasons behind 

these disparities are difficult to elucidate, but may be associated with health literacy, stroke 

recognition, access to care, socioeconomic status, patient mistrust, and provider bias (Boden-Albala 

et al., 2014). Communication elements, such as the use of vague words to describe stroke signs and 

symptoms during 911 calls, may also play a role (Richards et al., 2017). Recent patient surveys have 

shown thatin some populations, up to 75% of hospitalized stoke patients may be unaware of the 

connection between EMS use and favorable health outcomes after stroke (Xirasagar et al., 2019). 

Public awareness and educational initiatives have conventionally been regarded as integral for the 

early identification of stroke and early activation of the prehospital stroke system. While such 

interventions may increase stroke knowledge, limitations exist in the linkage to behavioral change 

in large, medically underserved populations (Boden-Albala et al., 2014; Prabhakaran et al., 2020). 

Further, targeted interventions may be necessary to increase individuals’ understanding of and 

trust in prehospital stroke care (Eisenstein et al., 2018). 

Proposed solutions include:

• Form local, state, and national policies to prioritize, comprehensively investigate, and work 

to create strategies for implementing sustainable community and health system-based

interventions aimed at reducing disparities.

• Create partnerships with local representative focus groups, which may explore the stroke 

knowledge base, attitudes, beliefs, and barriers regarding stroke treatment, as well as 

identify potential strategies for overcoming obstacles.

• Conduct more research and exploratory analyses aimed at fortifying linkages between 

educational initiatives and behavioral changes in large, medically underserved 

communities. 

• Identify strategies to augment engagement of local stakeholders and key community 

leaders.

EMS workforce diversity

Another perceived contributor to prehospital disparities in care is the ethnic/racial composition 

and diversity of EMS professionals, dispatchers, and other related personnel, which in some regions 
9 

has been cited to not be representative of the population they serve. In some reports, Hispanics 

and African Americans have been underrepresented in the EMS profession (Crowe et al., 2016). 

Additionally, a large survey of over 146,000 EMS providerswho were nationally certified between 

2017-2019 identified female sex and minority underrepresentation. The survey revealed that EMS 

professionals were primarily male (76%) and white (85%). By race/ethnicity, 85% were white, 5% 

were Hispanic/Latino, 5% were Black/African American, 2% were American Indian/Alaskan 

Native, 2% were Asian and 1% were Native Hawaiian/Pacific Islander (Rivard et al., 2021). Having 

a diverse workforce has been associated with improved access to healthcare for those in racial and 

ethnic minority communities, with greater patient choice and satisfaction, an overall improvement 

in the reported quality of care (Harker, 2016), and presumptive increased trust in the system.

Proposed solutions include:

• Diversity initiatives at health professional schools, including the removal of financial 

barriers for minorities, and inclusive policies for underserved and foreign-born candidates.

• Minority hiring programs in partnership with local civic and community groups.

• Sponsorship, support, and backing of EMT academies providing scholarships or other aid to 

minority students.

• Regional EMS diversity committees, with community and minority representation, to create 

recommendations for ongoing EMS diversity education.

• National advocacy organization level guidance for EMS diversity optimization strategies

and/or development of local/state policies to encourage EMS diversity initiatives.
10

Hyperacute and Acute Stroke Care

Prior to 1995, acute stroke treatment consisted primarily of supportive care during the immediate 

phase followed by rehabilitation and prevention of recurrent episodes. The introduction of 

intravenous tissue-type plasminogen activator (IV tPA) as a treatment for acute ischemic stroke 

revolutionized the stroke treatment paradigm. As a result, acute care shifted to immediate 

identification of potential stroke patients, rapid clinical and radiographic evaluation to confirm 

treatment eligibility, and drug administration within three hours of symptom onset. Stroke became 

a treatable disease (Grotta, 2021). 

Over the ensuing 22 years, advanced imaging techniques such as computed tomographic (CT), or 

magnetic resonance angiography (MRA) and perfusion imaging (CTP, MRP), along with the 

development of mechanical revascularization devices, have dramatically increased the pool of 

individuals who could benefit from emergent treatments. With the rapid identification of a vascular 

occlusion and significant salvageable brain tissue, patients could be treated within 24 hours from 

symptom onset with excellent clinical outcomes. 

Despite these advances, several barriers remain to rapid stroke identification and treatment of 

patients in the acute phase. Individuals who are potential candidates for intravenous and/or intraarterial therapy need to be identified quickly so they can be taken to hospitals capable of providing 

treatment. Geographic location, availability of telemedicine, communication and coordination 

services, and limited access to stroke expertise have all been cited as potential roadblocks to 

obtaining high level stroke care.

Stroke telemedicine (telestroke) has emerged as an effective way to reach stroke patients in 

emergency departments where vascular neurology expertise is required for decision-making. 

However, low-resourced hospitals in rural areas often lack access to broadband or telemedicine 

equipment needed for remote consultation. Other barriers include lack of financial and 

technological support, and misalignment of regulations and policy at the local, state/territory, and 

national levels (see Appendix B: Telemedicine in Stroke Care).

Competing health systems with overlapping “hub-and-spoke” territories may lead to patients 

bypassing the closest hospital in favor of one that is within the system. There are also disparities in 

physician licensing laws and competing insurance programs—particularly in areas where patients 

are transported across state lines. 

The acute stroke care workforce does not reflect the diverse population it serves, despite 

healthcare workforce diversity being shown to improve trainee experience, patient outcomes, and 

the quality of research. Another gap in our current knowledge is the potential benefit of more 

diverse healthcare professionals to patients’ well-being and medical knowledge.

Geography

Geographical inequities in access and delivery of acute stroke care include maldistribution of 

higher-level stroke hospitals and stroke expertise, nonuniform access to telemedicine, limited 

opportunities for continuing education for providers and patient communities, and low research 
11

participation by hospitals and patients in rural areas. Timely dissemination of impactful research 

findings (i.e., what thought leaders consider representative of “standard-of-care”) is also impacted 

by geography. 

Higher-level stroke hospitals, those designated as primary stroke centers (PSCs), thrombectomycapable stroke centers (TSCs), and comprehensive stroke centers (CSCs), are generally clustered in 

areas of high population density near academic institutions where stroke experts typically choose 

to work. Telemedicine is often employed to gain access to patients who require higher-level 

services, but telemedicine services are not always used in centers with a low volume and/or 

geographically isolated from higher-level stroke centers, which may be due tolimited access to 

reliable broadband internet.

Educational opportunities and support for leave from work for continuing medical education 

conferences are likely less robust in rural areas. Community education events focused on stroke are 

generally spearheadedby an individual or organization dedicated to the stroke mission through 

structured efforts. Personnel dedicated to this effort, and knowledge of the differences in how rural 

communities learn best, are needed to overcome disparities in stroke awareness.

Access to stroke centers

Several recent studies have mapped the distribution of PSCs and CSCs in the U.S. (Boggs et al., 2022; 

Schieb et al., 2015). Technology is available to facilitate the determination of distance, and even 

time, between where populations live and the closest appropriate hospital. But maintaining a 

comprehensive map of stroke resources is burdened by the rapid, continuous evolution of 

certifying hospitals (Boggs et al., 2022). 

Therefore, this issue needs to be revisited with frequency. The larger challenge is determining the 

most effective way to fill the gaps in access to quality PSCs, TSCs, and CSCs for definitive care and 

reduce the geographical disparity. Routing by state-funded “communication centers” can facilitate 

identification of the closest appropriate hospital based on patient location, clinical large vessel 

occlusion (LVO) screening, and time from symptom detection and/or last known well. This could 

ensure that patients with suspected stroke get to the right place at the right time and receive access 

to appropriate care. Additionally, initial destination protocols should be in place in all states and 

communication centers should have real-time recommendations for the closest appropriate 

hospital. A mechanism for crossing state lines toaccess closer emergency care and time-sensitive 

treatment should be provided. Lastly, ongoing education for implementation of protocols, clinical 

LVO screening in the field, and how to access communication centers is needed for prehospital 

providers. 

Telemedicine can help fill the gaps in access to neurological expertise needed for making 

emergency treatment decisions. However, telemedicine cannot convert a non-thrombectomy center 

into a thrombectomy center. Further, there are gaps in access to advanced neuroimaging, which 

may result in triaging patients to TSCs and CSCs far away from rural critical access hospitals. 

Expanding access to advanced neuroimaging can help rule out LVO or eligibility for recanalization 

therapy, saving time and allowing triage tocloser PSC certified hospitals. Moreover, significant 

financial resources are necessary to advance from one level of certification to another. Existing 
12

routing protocols create a self-fulfilling prophecy of feasibility to advance; if a center doesn’t get the 

patients, the center cannot demonstrate mastery, and investment may be futile.

Access to stroke expertise

While the majority (98%) of Americans live within 60 minutes of an emergency department (ED) 

(71% within 30 minutes), access to teaching hospital EDs is far more limited, particularly in rural 

states (Carr et al., 2009). Access to certified stroke centers is also a moving target, due to the 

evolution of hospitals through escalating certification programs. Eighty-one percent of Americans 

have access to intravenous-capable hospitals within 60 minutes and 56%have access to 

endovascular-capable hospitals, improving to 97%and 85%, respectively, if air ambulance is 

utilized (Adeoye et al., 2014). Stroke expertise is required for certification, which impacts some 

routing protocols. Hospitals without certification have less access to patients with acute stroke, and 

therefore have less opportunity to establish efficiency and proficiency without externalizing stroke 

expertise through telemedicine. In fact, studies have shown that over a two-year period from 2005-

2007, 64% of hospitals in the MEDPAR database had no reported treatments with IV tPA for acute 

ischemic stroke. Bed size, rural or underserved, stroke center designation, and population density 

were associated with reported tPA treatment rates (Kleindorfer et al., 2009). 

Emergency medicine (EM) residency programs lack standardization for exposure to managing 

stroke patients; many do not require residents to rotate on a neurology service (only 2% required 

stroke service exposure) nor to log stroke-related procedures, such as administration of tPA. There 

are also no stroke-specific ongoing education requirements for EM physicians. EM physicians who 

have been in practice for decades may have limited exposure to new, practice-changing clinical trial 

results, rendering deficiencies in identifying candidates for recanalization therapies. Access to 

trained stroke experts and vascular neurologists is limited. The ratio of the number of strokes per 

vascular neurologist in the U.S. is 717:1 (Charles Callison & Leira, 2008). Fellowship training of 

neurologists has kept pace with expansion of stroke centers, which particularly influences rural and 

underserved urban areas. The maldistribution of stroke interventionalists is even greater since a 

case load is necessary to maintain skills, which is particularly relevant for recent graduates of 

training programs. Even radiologists specializing in neurology may be deficient in some rural areas, 

placing greater responsibility on the neurologist.

To resolve the geographical disparities in access to stroke expertise, we need to increase the 

number of vascular neurologists and incentivize themto work in areas of shortage. We also need to 

motivate interventionalists to work in areas which will close the gaps in access to thrombectomy 

which may require modifications to credentialing requirements. Training and post-graduate 

education for EM physicians can improve proficiency in identifying and treating candidates for 

recanalization therapies. Accessing neuroradiologists or provision of automated intelligence 

technology to facilitate timely interpretation of computed tomography angiography (CTA)to 

identify LVO may improve the secondary transfer efficiency for thrombectomy candidates. 

Continuing education opportunities for providers and communities

Knowledge of stroke signs and symptoms is lower among adults in rural areas, where there is a 

higher prevalence of key stroke risk factors (i.e., hypertension, diabetes, and tobacco use) 
13

(Swanoski et al., 2012). Physicians in rural areas may have lower confidence in treating stroke 

acutely, perhaps due to a limited understanding of risks and benefits, and the knowledge and means 

to counsel patients on risk. Lower education, poverty and other macrolevel inequities likely 

contribute to participation, comprehension, and retention of such educational efforts. 

Research participation and dissemination of research findings

Literature on geographic disparities in medical research participation, particularly stroke research, 

is sparse. However, there is a consensus that small rural hospitals and clinics are less likely to be

involved in stroke research and, similarly, people in underserved geographic regions are less likely 

to participate in research studies. Clinical trial and study sites in the U.S. are highly clustered 

around urban areas with healthcare/social service facilities (Seidler et al., 2014). One common 

exclusion criterion for participation in a clinical trial is if the patient is unlikely to be able to 

complete all timepoints of measurement of outcomes, which is less feasible for patients who were 

“shipped” to a higher-level stroke center from a remote, rural region. Additionally, studies show 

that clinical trial leadership is clustered in urban, largely academic, centers in the U.S. and Western 

Europe (Hoekman et al., 2012).

There is lack of investment in existing research infrastructure and technologies in rural 

communities with less patients, who are already hesitate to participate in clinical trials. This is a 

barrier to providing research opportunities to underrepresented populations, which is critically 

needed to generalize clinicaltrial findings. Rural hospitals also may be less likely to fund clinicians 

or support time away from practice to attend national conferences, during which they learn about 

late-breaking, practice-changing trial results, making the effort to do so less appealing.

Policy and Regulation

Improving hub-and-spoke models 

Following evidence-based guidelines for time-sensitive recanalization therapy, starting with 

intravenous thrombolytic therapy, hospitals struggled to provide a new “standard-of-care” 

(Schwamm, Holloway, et al., 2009). Hospitals lacking on-site stroke expertise used to rely on 

emergency medicine physicians, who often have limited education and experience in the evaluation 

and treatment of high-risk procedures. Formal transfer protocols to off-load treated patients by 

transferring to higher-level stroke centers have successfully facilitated treatment in centers without 

on-site neurological expertise. The establishment of hub-and-spoke models, particularly as 

telemedicine technologies evolved, has brought more experienced neurologists to hospitals in need

of experts. 

Over time, individual hospitals have partnered with hospital systems for financial and management 

advantages, increasing the radius between hub and spoke hospitals, and creating overlapping 

systems within states. Consequently, patients often go directly to the “mothership” and bypass 

closer facilities, leading to a delay in definitive care when endovascular therapy is warranted and 

sometimes rendering patients as poor candidates for intervention. The physical separation impedes 

family and caregivers from being present during hospitalization and post-stroke rehabilitation, 

leading to added burden and stress for patients and their family.
14

Policy and legislation are needed to allow smaller hospitals to gain access to the closest appropriate 

hospital, potentially utilizing a neurological expert from a different hospital system. A centralized 

stroke command center could be used at the local level to help triage patients to the closest 

appropriate facility and determine the mode of secondary transfer (air vs. ground ambulance). This 

can be done using artificial intelligence, incorporating time from last seen normal, time from 

symptom detection, odds of harboring LVO, GPS data, road conditions, weather conditions, and 

location of all appropriate hospitals.

The key to efficiency in hub-and-spoke models is rapid, safe inter-facility transfer. Appropriate 

policies are needed to accommodate transfers to ensure all patients continue to receive quality 

stroke care during transportation and transfers. The spoke hospital is responsible for monitoring 

the patient and responding to a neurological deterioration while the patient is physically in the 

spoke facility. The hub hospital provides education for these activities and responds, when notified, 

of a clinical change. During the transfer, however, who owns the responsibility for managing the 

patient is more ambiguous. The Joint Commission considers it the responsibility of the certified 

center to establish expectations for monitoring the post-lytic patient before and during transfer, yet 

the legal responsibility for the patient may fall to the sending physician or to a “med control” 

authority under the umbrella of the EMS agency. Unless the hub hospital formally assumes this role, 

hub physicians may not be aware of potentially serious clinical changes. 

Standardization of education and materials for management and clinical documentation during 

secondary transfer could promote patient safety during this high-risk period, during which the 

stroke specialist is disconnected from the patient. Quality improvement efforts should be in place to 

troubleshoot avoidable adverse outcomes. 

State stroke care policies and regulations 

Based on a survey of stroke care policies and regulations across states, there is wide variability in 

rigor and robustness. A recent study examined stroke care laws and identified challenges for 

hospitals to comply with prescriptive standards (Centers for Disease Control and Prevention, 

Division for Heart Disease and Stroke Prevention, 2018). State registries/data repositories are 

needed to track patient outcomes but linking prehospitalEMS and hospital data has logistical 

challenges. Smaller hospitals with limited personnel resources may find participating in a stroke 

registry a burden, yet inclusion of data from these hospitals is necessary to avoid bias in the data. 

Moreover, some states certify stroke programs whereas others only recognize an external certifying 

entity (i.e., the Joint Commission, Det Norse Veritas, Healthcare Facilities Accreditation Program).

Economics and Healthcare Resources

Infrastructure and access to stroke expertise

Socioeconomic disparities in low-income neighborhoods substantially impact stroke care. This is 

likely due to the lack of telestroke services and stroke neurologists in rural and underserved areas. 

As per the MEDPAR database, 64% of the hospitals in the U.S. did not use IV tPA for acute stroke in 

the last two-year period. The direct cost of stroke, around $35 billion annually, is only the tip of the 

iceberg; the indirect costs like premature death, unemployment, and missed workdays increase the 
15

costs to $68.5 billion, bringing the total cost of stroke to $103.5 billion per year (Girotra et al., 

2020). Economic disparities contribute toeven more costs. The issue varies by state and U.S. 

territory. For example, Medicare pays less in Puerto Rico than the U.S. mainland, and this impacts 

where recent graduates choose to start their careers. Studies have shown that when medical 

students graduate, they are three times more likely to take a job in a U.S. state than a U.S. territory

(Beaton-Comulada et al., 2022). Such limited access to neurologists and stroke specialists, 

especially in rural areas and U.S. territories, significantly impedes stroke care. 

Resources for continuing education 

Stroke management is changing quickly. There are limitededucational resources in the low 

economic areas and rural hospitals to keep providers stay up-to-date on stroke guidelines. 

Education in stroke management may also help hospitals treat patients better. Knowledge 

regarding stroke symptomatology and the importance of going to the hospital quickly is lower in 

the rural communities (Swanoski et al., 2012). A lack of appropriate, currenteducation may lead to 

mismanagement of patients; providers could miss early symptoms and send patients home, which 

could lead to patients returning later with a major stroke. 

Demographics

Stroke workforce diversity

Having a diverse healthcare workforce is critically important to reducing health disparities. 

Maintaining a diverse healthcare workforce has been shown to1) improve the learning experience 

of diverse students and medical trainees; 2) improve patient care and health outcomes; and 3) 

improve the quality of healthcare research(Johnson et al., 2021; Sandset et al., 2019). 

Unfortunately, the current racial and ethnic diversity among the stroke, neurology, and 

neurosurgery workforce does not reflect the diversity of the U.S. population (Hamilton, 2016). A 

lack of diversity is a problem across the board in medicine (Lett et al., 2018; Salsberg et al., 2021), 

and stroke is no exception. Another concerning disparity is the lack of gender diversity in academic 

stroke medicine, especially in leadership positions (Cordonnier et al., 2019; Pikula et al., 2020). In 

addition tothe academic faculty workforce, there is also a lack of racial/ethnic diversity among 

neurology and neurosurgery trainees (including vascular neurology) (Das et al., 2021; Diversity in 

Medicine: Facts and Figures 2019. Figure 13: Percentage of U.S.medical school graduates by 

race/ethnicity, academic year 2018-2019., 2019; Hamilton, 2016; Kim et al., 2021; Salsberg et al., 

2021). In addition to having a low proportion of faculty and trainees from minoritized groups, 

individuals from minoritized groups who are part of the medical workforce face particular 

challenges in career advancement(Campbell et al., 2020). Challenges include the “minority tax,” 

“gratitude tax,” “loyalty tax,” “distance traveled,” “power distance,” and imposter syndrome. 

Although we still lack knowledge as to whether increasing diversity of the stroke workforce will 

reduce population health disparities, as well as which strategies would be most effective,there is 

some evidence for possible strategies to enhance diversity in the academic stroke workforce. 
16

Educating underserved and “at-risk” populations about stroke

Another priority that is critical to the reduction of disparities in acute stroke care is the need for 

improved outreach to underserved communities and to individuals at risk for inadequate stroke 

care. It has been well documented that race, ethnicity, urban/rural status, socioeconomic status, 

and other social determinants of health impact access to acute stroke care (e.g., thrombolysis, 

mechanical thrombectomy) (Attenello et al., 2014; Brinjikji, Rabinstein, et al., 2014; Hsia et al., 

2011; Messé et al., 2016; Mullen et al., 2014). Although the reasons for these disparities are 

multifactorial, patient and community related factors likely play a substantial role. For example, 

there is lower knowledge of stroke signs and symptoms among stroke survivors who are at risk for 

disparate treatment and outcomes—those who are Black, Hispanic, Spanish-speaking, those with 

lower income, low education, and those living in rural areas (DuBard et al., 2006; Jackson et al., 

2020; Patel et al., 2019; Swanoski et al., 2012). Adding to these disparities, educational acronyms 

(FAST/BE-FAST) for stroke signs and symptoms are primarily available in English. However,new 

Spanish language tools are being developed and studied (AHORA/RAPIDO).

Overall, the literature suggests differences in arrival time based on various sociodemographic 

factors, but the reasons for delays to hospital arrival are not well understood. Such reasons may 

include factors related to patient knowledge, community knowledge, self-efficacy, concerns about 

cost, prior experiences of racism/discrimination in the healthcare system, EMS provider knowledge

and implicit bias, concerns about immigration status, and lack of trust in the local healthcare 

system. Community-based educational initiatives may be the best approach to increasing stroke 

knowledge in populations at highest risk for disparities in care.

Potential solutions to the lack of diversity in the stroke workforce: 

• Track and measure diversity within the stroke workforce using targeted tools such as a 

Diversity Index (Salsberg et al., 2021). 

• Develop the role of diversity officers and Diversity, Equity, and Inclusion (DEI) committees 

within academic neurology departments, particularly regarding residency, fellowship and 

faculty recruitment. Formalize training in DEI by using certification programs (Bank et al., 

2017; Harpe et al., 2021; Mohile et al., 2021). 

• Make use of social media to increase networking and mentorship opportunities for diverse 

trainees and junior faculty (Corsini et al., 2021; Stamp et al., 2019). 

• Create multipronged and continuous “diversity pipelines” to help recruit and retain 

trainees to vascular neurology. Look to other specialties for successful examples of similar 

programs, such as emergency medicine (Clayborne et al., 2021), radiology (McintoshClarke et al., 2019), general multispecialty (Muppala & Prakash, 2021), and 

gastroenterology (Carethers et al., 2019). 

• Incentivize increased diversity in training and research programs through targeted 

funding opportunities (Campbell et al., 2020). 
17

There are several strategies with the potential to improve our understanding of delayed arrivals 

among those from minoritized groups. First, high quality studies evaluating the reasons for delays 

to hospital presentation are needed. Such studies should include data from stroke survivors, 

caregivers, and community members to help understand barriers to seeking immediate stroke care.

Further, future interventions must not only address improving patient knowledge of stroke 

warning signs but must address barriers to self-efficacy for patients from underrepresented groups. 

In addition, hospitals should be incentivized to engage with patients and community leaders to 

identify strategies (e.g., public education campaigns) aimed at decreasing delays to arrival. 

Disparities in stroke treatment must also be a funding priority for federal organizations to further 

incentivize investigators in this field.

Hospital resources and U.S. territories 

Disparities in hospital resources are another contributor to disparities in the care of patients from 

minoritized groups, and hospitals located in U.S. territories are no exception. One of the challenges 

that U.S. territories face is their distance from the continental U.S. The distance of U.S. territories 

from the rest of the U.S. creates an urgency to improve systems of care and hospital resources. 

Expanding telemedicine and increasing the number of medical professionals working in U.S. 

territories could help to address some of the disparities. Mentoring and education are also essential 

tools needed to improve the care of stroke patients living in U.S. territories. There is a need for new 

preventive medicine initiatives that help to decrease stroke risk and other chronic diseases that 

lead to increased risk of stroke.

A major gap in the current knowledge of stroke care and outcomes in U.S. territories is due to the 

lack of a comprehensive national registrywithstroke data from all the U.S. territories and Native 

American Nations. As part of our work for this task force, Dr. Rodriguez Mercado compiled data 

from the CDC on stroke care in Puerto Rico (PR) (from the Puerto Rican Stroke Registry, the largest 

stroke registry conducted among Hispanic individuals).Although not representative of allU.S. 

territories, the data from PR reveal multiple factors which may contribute to disparities in stroke 

care and outcomes—high prevalence rates of stroke risk factors, long arrival times and low rates of 

ambulance arrivals, and low rates of secondary prevention measures (see Table 1). 

Compared to data from the U.S. mainland, these findings are striking. For example, in this dataset, 

the median arrival time to the emergency room (from symptom onset) is over five hours, which is 

more than double the median arrival time reported in a similar study conducted in Worcester, 

Massachusetts (2 hours)(Goldberg et al., 2000), and much higher than arrival times from a registry 

in Stockholm, Sweden where median arrival time is 20 minutes (Ekelund et al., 2011; Members et 

al., 2009). Consistent with long delays in hospital arrival times, only one in five patients in the PR 

registry arrived by ambulance, compared to 45% in the U.S. mainland. Additionaldata from the PR 

stroke registry are listed belowin Table 1. 
18

Table 1: Demographics, Risk Factors, and Secondary Prevention Strategies in Stroke Patients 

in the Puerto Rican Stroke Registry

Demographics Sex: 52% female

Age (mean): 74 years, female; 69 years, male

Risk Factors Hypertension: 86%

Diabetes: 52%

Hyperlipidemia: 27%

Current smokers: 10%

Stroke Subtype Ischemic: 74.4%

Hemorrhagic: 18.2%

Hospital Arrival Metrics Time to hospital arrival (from symptom onset): 

5 hours, 30 minutes (median)

Ambulance arrival: 21%

Secondary Prevention Measures Activity recommendation: 17%

DVT prophylaxis at 2nd day: 41%

Stroke education: 31%

Lipid lowering agent: 72%

Stroke discharge checklist: 13%

Smoking cessation in smokers: 15%

All secondary measures met: 31%

Details of registry: Data abstracted from medical chart review (ICD-9 codes 430-438, TIAs excluded), 

January 1, 2007-December 31, 2009, from 21 participating hospitals in Puerto Rico. Study includes all 

patients hospitalized with an acute stroke in all hospitals with acute care capability in Puerto Rico. 

Total n = 3,999.

Acknowledgements: The collection of these data was funded by Puerto Rican resources, and data were 

collected in collaboration with the University of Massachusetts and the University of Miami.
19

Inpatient Stroke Care

Inpatient stroke care typically begins after acute therapies have been delivered and continues 

through inpatient rehabilitation. During this phase, stroke patients undergo diagnostic studies to 

determine the mechanism of stroke, are treated for potential complications, started on secondary 

prevention treatments, and assessed for rehabilitation needs. Remarkably, there is very little in the 

literature on inequities in access to or utilization of evidence-based approaches during this period.

For diagnostic studies, the report considers computed tomography (CT) and CTA magnetic 

resonance imaging (MRI) and MR angiography, carotid duplex and transcranial Dopplerultrasound, 

conventional cerebral angiography, echocardiography, cardiac rhythm monitoring, and standard 

blood tests (i.e., hemoglobin A1c, lipid panel). We also discuss several secondary stroke prevention 

interventions, including antithrombotic and statin therapies, carotid revascularization, closure of 

patient foramen ovale, and risk factor modification consultation.

We predicted that low-resourced regions of the U.S.would have fewer services, delayed 

implementation, and poorer patient outcomes. We also postulated that socioeconomic status 

impacts medical decisions. Financial factors may play a role in patients’ willingness to undergo 

inpatient testing or comply with treatment recommendations. Further, there may be implicit bias in 

determining which patients receive specific tests or referrals for interventions. Currently, the 

strongest evidence for this bias is gender-based.

Although data in the inpatient setting are scarce, evidence suggests that there are disparities in the 

management of patients with acute stroke. Identifying the factors that contribute to these inequities 

is critical for improving stroke outcomes and quality of life. Another challenge is a lack of data 

element standardization, which makes it difficult to interpret current research findings. The overall 

dearth of information related to inpatient diagnostic and interventional utilization highlights the 

critical need for future investigation.

Geography

Despite a lack of data on disparities in the delivery of inpatient care in the U.S., international data 

suggests that regions with depressed economies have fewer high resource facilities, and as a result, 

may not offer the same range of testing and interventions (Addo et al., 2012; Brinjikji, El-Sayed, et 

al., 2014; Langagergaard et al., 2011). In contrast, urban areas with a greater number of academic 

medical and comprehensive stroke centers may be able to provide a broad array of services, better 

meeting the needs of higher acuity stroke patients. However, this assumption may be flawed if 

socioeconomic factors interact with geography and impact decision-making during the inpatient 

period.

Several publications have explored the role of rurality on post-stroke care. Patients with complex 

conditions, including stroke, were shown to have reduced access to specialized support services, 

lack of coordinated care, experiences with providers with limited healthcare knowledge regarding 

their complex needs, and an increased risk of secondary complications. Studies have shown that a 

lack of continuity of care following transition back to the rural community results in increased 
20

emergency department visits and re-hospitalization within six months of discharge (Danzl et al., 

2016; Kitzman et al., 2017). Home-based and telehealth tools were found to be helpful in alleviating 

patient barriers to post-stroke care. Also, robotic therapies were found to reduce cost and increase 

access in a rural setting focused on veteran stroke survivors (Custodio et al., 2009; Housley et al., 

2016; Morrell et al., 2017). 

Gap areas and research opportunities

• The characteristics of rural and urban hospitals that contribute to inequities in delivery of 

in hospital and post-stroke care should be further studied.

• The influence of geographic location of hospitals and availability of the most up to date 

equipment, protocols, and expertise should be explored in relation to the effect on stroke 

outcomes.

• The role of technologies (such as telemedicineand robotics) in reducing disparities should 

be investigated in the inpatient and post-stroke rehabilitation setting.

Policy and Regulation

In 1985, the U.S. Department of Health and Human Services released the Secretary’s Task Force on 

Black and Minority Health (the Heckler Report). As one of the first federal documents to highlight 

healthcare disparities between majority and racial and ethnic minority populations, it is important 

to note the emphasis that this document placed on advances in health information technology (HIT)

in the necessary reforms. The report also emphasized systems development over individual patient 

care. There was also an emphasis on systems development over individual patient care. Since the 

start of the COVID-19 pandemic in March 2020, the progress in remote care has been 

unprecedented.

In August 2021, Duncan et al. appropriately asked, “Has the time come for telerehabilitation?” In 

this commentary, the authors note that the very systems in need of better HIT integration (e.g., 

prisons, rural healthcare, etc.) were the early adopters.Telerehabilitation has been shown to be 

non-inferior to inpatient care to improve stroke impairments and quality of life in both the patient 

and the caregiver (Cramer et al., 2019). While disparities to telerehabilitation appear to overlap 

with both socioeconomic status and geography creating a digital divide, strategies to improve 

technology access may help to limit their effect as well(Caughlin et al., 2020; Custodio et al., 2009; 

Duncan & Bernhardt, 2021; Strowd et al., 2021). 

Gap areas and research opportunities

• Insurance coverage is often a barrier and a driver of disparities. The U.S. Department of 

Veterans Affairs (VA) has direct appropriation from Congress, and therefore, can decide 

what it supports. From an equity standpoint, this is a positive approach. More data on the 

impact of insurance is needed.

• Hospital certifying agencies could consider policies designed to eliminate barriers to 

equitable delivery of care. 
21

• There is potential value in distributing protocols from CSCs, representing a bundle for inhospital stroke care, to all hospitals across a network to promote standardized practices, 

which should also promote more equitable care.

Economics and Healthcare Resources

It is difficult to tease out the combined effects of geography, socioeconomic status, and 

race/ethnicity on equitable delivery of inpatient care. An analysis of the National Inpatient Sample 

identified several factors associated with reduced utilization of inpatient implantable cardiac 

monitor (ICM) placement for detection of paroxysmal atrial fibrillation. Multivariate analysis 

revealed that hospital region [Midwest (OR 0.74 95% CI 0.61 - 0.90, p = 0.002), South (OR 0.68 95% 

CI 0.57 - 0.81, p < 0.001), and West (OR 0.37 95% CI 0.29 - 0.45, p < 0.001)], hospital bed size [small 

(OR 0.38 95% CI 0.39-0.46, p < 0.001) and medium hospital bed size (OR 0.73 95% CI 0.63 - 0.84, p 

< 0.001)], insurance status [Medicaid (OR 0.86 95% CI 0.76 - 0.98, p = 0.02) and self-pay (OR 0.51 

95% CI 0.41 - 0.62, p < 0.001)], and non-teaching hospital (OR 0.52 95% CI 0.47 - 0.60, p < 0.001) 

were associated with a lower likelihood of having an ICM placed (Yaghi et al., 2022). 

Evidence of the association between racial/ethnic health disparities and socioeconomic differences 

is very consistent across chronic illnesses and health care services. We found several publications 

evaluating the influence of neighborhood socioeconomic status (nSES) on post-stroke recovery. 

Higher nSES was associated with better function, biopsychosocial health, physical health-related 

quality of life, and fewer depressive symptoms when compared to lower nSES. In addition, 

mortality after stroke was significantly higher among residents from lower nSES (Brown et al., 

2013; Elfassy et al., 2019; Stulberg et al., 2021; Twardzik et al., 2019). 

Stroke rehabilitation referral patterns

Referral patterns also affect the provision of post-stoke care. The literature suggests that women 

were less likely to receive inpatient rehabilitation compared to men. Similarly, higher 

socioeconomic groups, patients from urban areas, and patients from geographic areas close to

regional rehabilitation hospitals were more likely to go to an inpatient rehabilitation facility. 

Underinsurance is a likely barrier to rehabilitation services. Referral patterns also affect the 

provision of post-stoke care. The literature suggests that women were less likely to have inpatient 

rehabilitation than men. Similarly, higher socioeconomic groups, patients from urban areas and 

from geographic areas close to the regional rehabilitation hospitals were more likely to go to an 

inpatient rehabilitation facility. Referrals to home health services were more often provided to 

racial minorities, females, older individuals, and those with lower incomes. Conversely, uninsured 

individual and rural residents were less likely to receive home health services. Blacks, females, 

older individuals, uninsured individuals and those with lower incomes were less likely to use 

skilled nursing facilities rather than acute inpatient rehabilitation hospitals (Freburger et al., 2011; 

Sandel et al., 2009).

Based on these findings, further research is needed to evaluate the structural and social 

characteristics of neighborhoods that may contribute to post-stroke recovery and mortality. 

Evaluating referral patterns and the use of community care coordinators within regions of lower 

nSES maybe a useful adjunct to care following acute stroke admissions.
22

Gap areas and research opportunities

• Telemedicine can provide some opportunities not available in traditional in-person visits. 

This may include (but is not limited to) joint discussions with family members whoare 

geographically dispersed. Reimbursement for telehealth has been robust during the COVID19 pandemic, but whether insurers will continue to cover telehealth remains uncertain. 

• Many patients don’t have access to a smartphone or internet connectivity to support 

telemedicine video interactions. The VA recently addressed some of these issues by loaning 

patients a tablet with a data plan, which provides cost benefits when compared to not 

providing care. However, this approach would be difficult to apply to the general population

and more research is needed on its effectiveness. Although preliminary, the VA also recently 

developed local community pods with tech support to bring telehealth to underserved areas

(see Appendix B: Telemedicine in Stroke Carefor more details on telestroke).

• Secondary stroke prevention usage declines with age, despite the risk of stroke increasing

with age. Possible explanations include comorbidities and other risk factors preventing 

use of certain medications or limitations due to cost. More research is needed on this 

pattern. It is also important to examine what causes medication noncompliance at certain 

timepoints after discharge (e.g., 30, 60 days, etc.).

• More research is needed on how different types of post-discharge care affect patient 

outcomes (e.g., primary care physician [PCP], community-based health clinics). 

Demographics

Secondary stroke prevention measures

In the previously referenced analysis of ICM inpatient placement, from the National Inpatient 

Sample, Black race was associated with decreased utilization (OR 0.76 95% CI 0.68 - 0.84, p < 

0.001) (Yaghi et al., 2022). Compared to younger patients, those aged 65 years and older in the 

REGARDS study were less likely to be prescribed a statin at discharge (OR 0.75, 95% CI 0.57, 0.99), 

but there was no significant difference by sex, race, education, income, or residence (Albright et al., 

2017). Hispanics in Puerto Rico had lower odds of being prescribed a statin (adjusted OR 0.23, 95% 

CI 0.12, 0.47) compared to non-Hispanic whites (Sacco et al., 2017). In the same cohort, patients 

aged 65 years and older were no less likely to be prescribed antithrombotic therapy at discharge 

based on race/ethnicity (Sacco et al., 2017). Based on data from the Get with the Guidelines (GWTG) 

program, Asian Americans had a higher odds of being prescribed a statin compared to Whites

(adjusted OR 1.25, 95% CI 1.16, 1.35 than Whites)(Song et al., 2019). 

Guidelines recommend antithrombotic administration within two days of hospitalization. In the 

GWTG Florida and Puerto Rico cohort, compared to Whites, Hispanics from Puerto Rico had lower

odds of receiving an antithrombotic by end of hospital day two(adjusted OR 0.24, 95% CI 0.10, 

0.55). However, in patients aged 65 years and older, there was no significant difference by

race/ethnicity for antithrombotic use by end of hospital day two.In GWTG, compared to Whites, 
23

Asian Americans had higher odds of receiving an antithrombotic within 24 hours of hospital 

admission (adjusted OR 1.10, 95% CI 0.99-1.21)(Sacco et al., 2017). 

Antiplatelet prescribing at the time of stroke discharge was also evaluated in these populations. In 

the GWTG Florida and Puerto Rico cohorts, Hispanics from Puerto Rico had lower odds of being 

discharged on an antithrombotic (adjusted OR 0.29, 95% CI 0.12–0.74) compared to whites. In 

patients with atrial fibrillation, Hispanics from Puerto Rico were less frequently discharged on 

aspirin (Blacks 43.6%vs. 42.2% White, 35.5% FL-Hispanic, 11.1% PR-Hispanic) (Sacco et al., 2017). 

In addition, in patients aged 65 years and older, there was no significant difference by 

race/ethnicity for antithrombotic prescribed at discharge (Sacco et al., 2017). In symptomatic 

carotid endarterectomy patients, women were less frequently discharged on an antiplatelet 

compared to men (women 95.9% vs. men 96.6%, P = 0.007) (Dansey et al., 2020). 

Multiple U.S. studies have found that women and non-white individuals are less likely to receive 

secondary stroke prevention therapies, including antiplatelet and anticoagulation medications. In 

symptomatic carotid endarterectomy patients, women were less frequently discharged on an 

antiplatelet than men (women 95.9% vs. men 96.6%)(Dansey et al., 2020). Interestingly at least 

one study found that non-White subjects, women, and those with lower education were less likely 

to see a cardiologist, which is important as multiple studies have shown that seeing a cardiologist is 

more likely to be associated with guideline-based care for atrial fibrillation.

Access to post-stroke rehabilitation services

Blacks, females, older individuals, uninsured individuals and peoplewith lower incomes were less 

likely to use skilled nursing facilities compared to acute inpatient rehabilitation hospitals

(Freburger et al., 2011; Sandel et al., 2009). Despite data revealing no clinically significant racial 

difference in rehabilitation therapy utilization or intensity, there are considerable differences in 

functional outcomes. Blacks were less likely to achieve comparable functional improvement 

following rehabilitation. A pertinent factor noted was that Black patients underwent more frequent 

post-stroke transitions. Therefore, racial differences in discontinuous care and suboptimal 

transitions between settings may play a role in patient outcomes (Ellis et al., 2015; Ellis et al., 2014; 

Skolarus et al., 2017). Based on these findings, further research is needed to evaluate the 

consequence of care transitions in patients with stroke and strategies to optimize or decrease 

transitions are needed.

Gap areas and research opportunities

• Further studies are needed to address demographic inequities in the utilization of 

inpatient procedures, such as carotid interventions and patent foramen oval closure. 

• Demographic variations in diagnostic procedures and prescribing secondary stroke 

prevention medications during hospitalization requires further study. 

• The impact of demographic inequities in the use of secondary stroke prevention measures 

and post-discharge disposition on stroke outcomes should be investigated.
24

Action Opportunities

The section below serves to summarize tangible actions and potential solutions gleaned from the 

task force reports and the March 2022 Inequities in Access and Delivery of Acute Stroke Care

symposium. Formulated by thoughtful discussions, the steering committee and task forces agreed 

that the following recommendations represent a path forward toresolving disparities in stroke 

care.

Prehospital Stroke Care

As mentioned prior, prehospital care emerged as a primary focus of the symposium because 

deficiencies in early recognition, triage, and transport have clear downstream impacts on treatment 

options, care venues, and clinical outcomes. To better convey potential action opportunities in this 

care epoch, the task force presented their recommendations in three categories.

Education and training

1. Enhance education and trainingin stroke recognition among emergency medical 

services (EMS) professionals, throughout the chain of survival (i.e., dispatch, fire and 

rescue, police, paramedics, and others), especially in rural areas and U.S. territories.

2. Implement statewide policies to promote the use of nationally validated prehospital 

large vessel occlusion (LVO) stroke scales as they evolve.

Stroke systems of care

3. Encourage research tofurther optimize adaptive, ‘real time’ prehospital routing 

algorithms based on location, patient characteristics, local resources, and transport 

times.

4. Enhance access to prehospital stroke research across geographic barriers and

promote prehospital triage programs for U.S. territories and native peoples’ 

communities/reservations. 

5. Standardize prehospital communications within stroke systems of care to ensure 

universal prenotification in acute stroke triage. 

6. Incorporate community paramedicine and local partnerships into stroke systems of 

care.

7. Establish linkages between prehospital and hospital patient care records to enable

real-time patient care and quality improvement activities. 

Government and regulatory

8. Pass legislation to promote standard EMS protocols and regionalization of 

prehospital stroke care across and within states and U.S. territories. 

9. Advocate for policies, legislation, and resources to support the creation of state or 

community-level stroke registrieswith the capacity to link prehospital data to 

health system outcomes and serve as a basis for policy development and continuing 

quality improvement initiatives.
25

10. Enlist panels of community stakeholders and local and regional stroke care advisory 

groups. 

11. Develop financial aid and loan repayment programs for EMS professionals and 

support paramedic stroke training specific torural and resource-limited settings. 

12. Partner with commercial telecommunication providers and emergency services to 

enhance cellular and broadband capability for rural ambulance agencies. 

13. Pilot prehospital telemedicine services (telestroke) to support LVO scale validation, 

assessment, and triage. 

14. Provide guidance to states regarding minimum elements required for prehospital 

stroke systems of care, including the role of stroke advisory committees. 

15. Support Centers for Medicaid and Medicare reimbursement guidelines that promote 

reimbursement for prehospital care commiserate with the level and complexity of 

care (e.g., value-based reimbursement, reimbursement ofnon-transports and

alternative destination transports, mobile stroke units and telestroke consultation, 

and "code stroke" billing modeled from trauma activation billing).

Hyperacute and Acute Stroke Care

During discussions about acute care in the emergency department setting, access to high-level 

stroke centers and expertise emerged as a ubiquitous disparity. The task force focused their 

recommendations on potential short- (1-3) and long-term (4-6) solutions to expand stroke 

expertise to where it’s needed, improve hospital infrastructure and resources, and remove policy 

and regulatory barriers to receiving high-quality stroke care.

1. Develop a student loan repayment program for stroke neurologists and 

interventionalists to enhance employment and practice. This could ensure that 

lower-resourced hospitals achieve higher levels of stroke certification, thereby 

improving access to stroke expertise.

2. Seek out National Institutes of Health (NIH)funding (via NIH StrokeNet) to support 

research and education for rural stroke coordinators who work with smaller 

hospitals and remove barriers toparticipation, including the lack of research 

infrastructure.

3. Provide community-based stroke educational opportunities to the public and stroke 

care professionals, especially in rural and low-income areas. 

4. Develop a Mobile Intervention Stroke Team (MIST) model to improve regional 

access to thrombectomy and reduce extended transfers, which contribute to 

disparities in the ability of families to support patients, understand post-stroke 

dependency, and obtain adequate stroke education. These issues are exacerbated by 

disparities in socioeconomic status.

5. Develop strategies to encourage telestroke adaptation at appropriate hospitals. 

6. Stroke care professionals should work at the local, state/territory, and national level 

to coordinate stroke care. 
26

Inpatient Stroke Care

Patient outcomes were a common theme in this care epoch because the quality of inpatient stroke 

care often has major impacts on patient recovery, post-stroke disability, and long-term health

outcomes. Additionally, recognizing the lack of literature on inequities in access to inpatient stroke 

treatments and services, the task force recommendations focused on ways to enhance research on

inpatient and post-stroke care. 

1. Social determinants of health play major roles in patient outcomes (e.g., medication 

usage, follow-ups). Therefore, there is a need for more community health needs 

assessments to improve medication compliance and post-hospitalization outcomes. 

2. Stroke nurse navigators can help guide the transition from inpatient to outpatient 

care, including outpatient follow-up and ensuring consistent medication usage.We 

should support and diversify the stroke nurse navigator workforce.

3. To reduce costs and optimize patient outcomes, there is a need for more research on 

how the duration of inpatient rehabilitation affects patient outcomes. 

4. Evaluate ethnicity/race, geography, patient education, income, and health insurance 

interaction to accurately describe existing disparities in inpatient medication 

prescribing (i.e., early antithrombotic administration) and discharge prescribing of 

secondary stroke prevention medications. 

5. Establish and adopt standardized categories and terminology, potentially by 

requiring researchers to use NINDS Common Data Elements in publications. There 

is also a need to improve the definitions ofpatient-level (e.g., non-adherence), 

provider-level (e.g., risk assessment/benefit), and societal-level (e.g., drug costs)

factors. 

6. Additional research is needed to determine how best to facilitate the community 

navigation necessary to encourage positive health outcomes for individuals 

transitioning back into low-resourced rural communities. 

7. Assess which characteristics of rurality and other demographics are most salient to 

the inpatient and post-stroke care experience.
27

Conclusion

Mark J. Alberts, M.D.

Brain Attack Coalition Chair and Symposium Steering Committee Co-Chair

Combined with knowledge gained from the symposium, the findings from the expert task forces 

revealed several common and overlapping causes and associations that appear to directly impact 

disparities in stroke care, potentially leading to poor health outcomes. Fortunately, several themes 

emerged that might provide opportunities to address these disparities comprehensively and 

efficiently. Below we summarize some areas that might be easy to address in a short-term time 

frame (1-2 years) and others that might require more long-term efforts (3-5 years) due to their 

high complexity or need for major funding or policy changes.We acknowledge that important 

initiatives, such as primary prevention programs, are very useful but will require high-cost 

investments lasting 10-20 years, which is beyond the scope of this work.

The development of a regional and/or national stroke registry would benefit patients from all 

backgrounds in every area of the country. A registry would provide transparency about the 

efficiency and effectiveness of care nationwide and provide important insights into key associations 

that would track with disparities of care in all care epochs and locations. To the extent that some 

registries currently exist in various states, and implementation of these registries typically does not 

require major advances in technology or infrastructure, regional or national efforts could be 

implemented in a relatively short time. Such registries might be highly impactful in terms of 

refining care for high-risk populations.

A lack of knowledge about stroke risk factors, poor recognition of stroke symptoms, and an 

underutilization of911 remains a vexing problem for many high-risk populations, including 

persons in minority and underserved groups. There is robust literature about the effectiveness of 

culturally sensitive approaches to public education, as well as the need for stroke awareness 

programs to frequently update messaging and dissemination strategies. For example, Mind Your 

Risks®—a public health campaign designed to raise awareness about the link between high blood 

pressure, stroke, and dementia—was recently updated to focus on Black men between the ages of 

28-45, a group most at-risk for hypertension. Building on their prior success, programs using the

FAST or BE-FAST mnemonic should be relaunched in the current era of highly effective mechanical

thrombectomy. Reviving them now may further promote rapid and accurate stroke recognition.

Emergency medicine emerged as a key venue for improvement in care for all populations, 

especially people of color. We identified several potential short-term solutions, including 

establishing national prehospital standards of care and related metrics and creating adaptive 

emergency medical services (EMS) routing algorithms. Long-term solutions include increasing the

use of telestroke in the field and developing a more diverse workforce. EMS officials should partner 

with local groups, especially those that represent minority areas and populations, for public health 

education and related initiatives. EMS officials might also consider partneringwith federal agencies 

(e.g., the Centers for Disease Control and Prevention), state-health offices, advocacy groups, and 

others.
28

In the acute care space, expanding telestroke services to underserved areas (especially rural 

facilities and hospitals) could alleviate some identified disparitiesrelatively quickly. Over the next 

several years, increasing the availability and use of mobile stroke units might be cost-effective, 

depending on the density of high-risk populations and distances between various levels of 

hospitals. The “triage and treatment paradigm”used to ensure timely and efficient transfer of 

specific types of patients with myriad emergency conditions could be implemented in stroke care 

within a shorttime frame. This is also an example of howstate or regional policymakers can work 

together to remove barriers toaccess to stroke care (i.e., insurance rules). 

The quality of inpatient care and post-discharge care often has major impacts on patient recovery, 

post-stroke disability, and risk of subsequent cerebrovascular and cardiovascular events. We 

identified significant disparities in the use of validated and proven secondary prevention modalities 

(e.g., medications, surgery, and endovascular therapy), availability of acute rehabilitation services, 

and other special services such as mental health support. Regarding secondary prevention, 

treatments are widely available, and programs exist to enhance compliance with national 

standards. In the shortterm, novel, focused incentives for diverse providers and patients should 

support the adoption of the national standards for secondary stroke prevention,while also 

addressing concerns about treatment side effects, affordability, and other patient concerns or 

barriers in a culturally sensitive manner. 

Though not in the original scope of this effort, all three time epochs of acute stroke care noted 

access to rehabilitation and mental health services as a point of disparity. This is further 

complicated due to the existence of pervasive barriers, including financial support, lack of facilities 

near acute care hospitals as well as where patients live, and a paucity of mental health resources in 

areas with high-risk populations. Fortunately, the use of telehealth technologies, such as 

telerehabilitation and telepsychology, offers one approach to address these disparities in the long 

term. The thoughtful use of advanced practice providers and other modalities ofhome-based care 

might be another, partial solution to these challenging issues.

Disparities and inequities exist within all levels of stroke care. Although the root causes of these 

differences are as diverse as the populations impacted, several common themes have emerged that 

may offer pathways forward to address some of these concerns in a sensitive and thoughtful 

manner. There are options with both short- and long-term horizons. No matter the action, the 

sooner that stakeholders and relevant organizations can formulate and implement solutions, the 

sooner people at high risk will benefit.
29

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40

Appendix A: Brain Attack Coalition Symposium 

Agenda and Recordings

Inequities in Access and Delivery of Acute Stroke Care

March 17-18, 2022

Agenda

Day 1

Thursday, March 17, 2022 (all times Eastern Standard Time)

Master of Ceremonies: Samantha White, Ph.D., National Institute of Neurological Disorders and 

Stroke (NINDS)

10:15am Welcome

Mark Alberts, M.D., Hartford Hospital, University of Connecticut

Richard Benson, M.D., Ph.D., NINDS

10:30-11:15am Keynote Address

David Satcher, M.D., Ph.D., Founding Director and Senior Advisor of the 

Satcher Health Leadership Institute

11:15-12:30pm Prehospital Care Report Out with Breakout Discussions by CrossCutting Theme

Moderator: Mark Alberts, M.D., Hartford Hospital, University of Connecticut

This day and a half event brought together Brain Attack Coalition organizations and task force 

members with stakeholders and providers to share findings and identify opportunities for 

synergy in the identification of equity issues, their known and/or unknown causes or obstacles, 

and establishing best practices or possible solutions concerning stroke care across three time 

epochs: prehospital, hyperacute and acute, and inpatient care. Participants examined inequities 

across four cross-cutting themes: geography, policy and regulatory issues, economics and 

healthcare resources, and demographics.

Symposium goals: 

The long-term goals of the symposium include improving stroke systems of care, providing 

more efficient and effective treatments, increasing equity in access and care, and improving 

outcomes for all affected populations.

Video recordings are available on NIH videocast (watch Day 1 and Day 2).
41

Todd Crocco, M.D., University of Maryland

Erika Odom, Ph.D., Centers for Disease Control and Prevention

11:15am – Presentation

11:30am – Moderated Q&A Session

12:00pm – Breakout Discussions

12:30-1:15pm Lunch Break

1:15-2:30pm Hyperacute and Acute Care Report Out with Breakout Discussions by 

Cross-Cutting Theme

Moderator: Mary (Lee) Jensen, M.D. University of Virginia

Ameer Hassan, D.O., University of Texas Rio Grande Valley

Mary (Lee) Jensen, M.D., University of Virginia

1:15pm – Presentation

1:30pm – Moderated Q&A Session

2:00pm – Breakout Discussions

Inpatient Care Report Out with Breakout Discussions by CrossCutting Theme

Moderator: Mark Alberts, M.D., Hartford Hospital, University of Connecticut

Karen Furie, M.D., Brown University

Lawrence Wechsler, M.D., University of Pennsylvania

2:30pm – Presentation

2:45pm – Moderated Q&A Session

3:15pm – Breakout Discussions

3:45pm Break

4:15-4:50pm Breakout Discussion Summary and Wrap Up

Moderator: Mark Alberts, M.D., Hartford Hospital, University of Connecticut

4:50-5:00pm Closing Remarks

Walter Koroshetz, M.D., Director of NINDS

5:00pm Adjourn
42

Day 2

Friday, March 18, 2022 (all times Eastern Standard Time)

Master of Ceremonies: Samantha White, Ph.D., NINDS

11:00am-12:30pm Synthesis and Discussion of Day 1 Dialogues: Confirmations, 

Corrections, and New Ideas

Moderator: Mark Alberts, M.D., Hartford Hospital, University of Connecticut

Moderator: Richard Benson, M.D., Ph.D., NINDS

Prehospital Care Synthesis

Charles (Chas) Wira, M.D., Yale University

Hyperacute and Acute Care Synthesis 

Mary (Lee) Jensen, M.D., University of Virginia

Inpatient Care Synthesis 

Karen Furie, M.D., M.P.H., Brown University

Lawrence Wechsler, M.D., University of Pennsylvania

12:30-1:00pm Symposium Wrap Up

Mark Alberts, M.D., Hartford Hospital, University of Connecticut

Richard Benson, M.D., Ph.D., NINDS

1:00pm Adjourn
43

Appendix B: Telemedicine in Stroke Care

Telestroke is one of the most successful applications of telemedicine, bringing stroke experts to 

hospitals where they are most needed. Telestroke systems of care were designed to address 

disparities in access to neurologic expertise (Demaerschalk et al., 2012; Schwamm, Holloway, et al., 

2009; Wechsler et al., 2017). Current American Heart Association/American Stroke Association 

(AHA/ASA) guidelines for the early management of acute ischemic stroke recommend that 

“telemedicine/telestroke resources and systems should be supported by healthcare institutions, 

governments, payers, and vendors as one method to ensure adequate 24/7 coverage and care of 

acute stroke patients in a variety of settings” (Powers et al., 2019). 

But despite the rapid growth of telestroke over the past two decades, and further expansion during 

the coronavirus disease (COVID-19) pandemic, significant disparities in access to telestroke persist, 

with lower rates of adoption in rural areas, and ostensibly in hospitals that would greatly benefit 

from telestroke services (Machado et al., 2021; Richard et al., 2020). 

Beginning in 2020, the pandemic led toloosened state licensure requirements for who can provide 

telemedicine and where providers and recipients can be located (e.g., in different states); however, 

not all states have made these provisions. Further, not all insurers or plans reimburse for the 

services, telemedicine parity laws are variable, and there are limitations on audio-only 

consultations. Moreover, qualifications of the healthcare provider are inconsistent. In some 

systems, neurosurgeons and non-stroke neurologists participate in telestroke calls, rendering 

inconsistency in education and experience. In the acute care setting, telestroke evaluations are 

especially helpful for quick and correct thrombolysis eligibility decision-making, and triaging 

patients for emergency mechanical thrombectomy.Provision of stroke-specific education and 

validation ofthe application of AHA/ASA Guidelines for the Early Management of Patients with 

Acute Ischemic Stroke may improve the proficiency of identifying and treating candidates for 

recanalization therapy (i.e., intravenous thrombolytic, thrombectomy).

Based on our findings, disparities in access to telestroke may be due to lack of infrastructure like 

broadband internet, higher costs, inadequate funding, limited technology, and policy and regulation 

hurdles. Overall, more research is needed to understand and address these issues.While the 

findings below focus on the role of telestroke in the acute care setting, many observations and 

recommendations can be applied to all aspects of stroke care.

What is currently known about telestroke? 

• Telestroke is the use of real time audiovisual telecommunications to provide stroke 

expertise and decision support for remote access patients and emergency providers in the 

acute stroke setting (Levine & Gorman, 1999). 

• Telestroke/teleradiology evaluations of acute stroke patients can be effective for correct 

thrombolysis eligibility decision-making (IIa, B-R) (Powers et al., 2019). 

• Telestroke services that utilize video-based consultation compared with telephone-only 

consultation are more accurate in determining eligibility for intravenous thrombolysis for 
44

patients presenting with acute stroke signs and symptoms in the emergency department 

(Demaerschalk et al., 2012). 

• When implemented within a telestroke network, teleradiology systems are effective in 

supporting rapid imaging interpretation in time for thrombolytic administration decision 

making. (I,A) (Powers et al., 2019). 

• Telestroke networks may be reasonable for triaging patients with acute stroke who may be 

eligible for interfacility transfer in order to be considered for emergency mechanical 

thrombectomy (IIb, B-NR) (Powers et al., 2019). 

• The use of telemedicine/telestroke resources and systems should be supported by 

healthcare institutions, governments, payers, and vendors as one method to ensure 

adequate 24/7 coverage and care of acute stroke patients in a variety of settings (I, C-EO) 

(Powers et al., 2019). 

What are the gaps and opportunities?

• Smaller, rural, critical access hospitals are less likely to have adopted telestroke systems 

compared to larger, urban hospitals and short-term acute care facilities.

• Neurologist density has decreased in rural counties in the U.S., and existing neurologists in 

rural settings are aging out of their careers (Machado et al., 2021). 

• Telestroke capacity in 2017 (Richard et al., 2020): 

o Hospital size: highest quartile (33.5%) vs. lowest quartile (14.8%)

o Location: urban (30.2%) vs. rural (23.5%)

o Type: short term acute care (31.7%) vs. critical access (17%)

• Telestroke units/county in 2018 (Area Health Resource Files, CDC data) (Machado et al., 

2021): 

o Telestroke units are available in 51%, 37%, and 18% of large metropolitan, 

medium/small metropolitan, and rural counties, respectively. 

o Notably, 4 out of 5 rural counties do not have a telestroke unit. 

• Barriers to adopting telestroke services in rural and critical access hospitals include, cost, 

capacity, local/state/federal policies and regulation, technological limitations, availability of 

rural broadband, and availability of telestroke providers. 

• There is a lack of prospective, comparative research to confirm the effectiveness of 

telestroke and telestroke systems in the acute stroke treatment and interfacility triage of 

patients with large vessel occlusion.

How can we make improvements to dissolve these geographical disparities? 

• Expand licensure to perform telestroke services across state lines. 
45

• Allow universal parity between stroke care performed via telemedicine and in-person 

services.

• Maintain elimination of originating site restrictions for telestroke services.The 2018 FAST 

Act requires Centers for Medicare and Medicaid Services to reimburse for telestroke 

services regardless of where a patient receives treatment.

• In situations where video-based consultation is not available, allow reimbursement of 

emergency telephone consultation with stroke providers as a limited telephone-only 

encounter.

• Continue policies enacted within the COVID-19 Emergency Authorization Act that 

incentivize the adoption of telestroke services across all geographies.

• Stroke experts should work with legislature, policy makers, regulatory agencies, and 

commercial telecommunications providers to ensure access to high quality broadband for 

rural hospitals and settings.

• Empower state departments of health, governmental agencies, and regional health systems 

to partner in enabling the provision of telestroke services for critical access hospitals within 

stroke systems of care. 

• Create more federal grant funding opportunities for the adoption of telestroke programs 

and networks for rural and critical access hospitals (e.g., Health Resources and Services 

Administration, Agency for Healthcare Research and Quality, Centers for Disease Control 

and Prevention, National Institutes of Health).

• Develop loan repayment programs for telestroke providers who provide care for ruralbased hospitals, with the long-term goal of growing and incentivizing the telestroke 

workforce.

• Work with the Accreditation Council for Graduate Medical Education (ACGME) and 

specialty boards to instill educational and training requirements in telemedicine 

competency (i.e., telestroke skills for neurologists and stroke fellows in training).

• Promote skills training and certification for emergency providers, nurses, and support staff 

in telestroke competency.

• Expand telestroke research by integrating telestroke into acute stroke clinical trials and

epidemiological studies and developing multicenter telestroke research networks.
46

Appendix C: Steering Committee and Task 

Force Members

Steering Committee

Co-Chairs

Mark J. Alberts, M.D.

Co-Physician-in-Chief

Ayer Neuroscience Institute 

Chief of Neurology

Hartford Hospital

Professor

University of Connecticut Medical School

Richard Benson, M.D., Ph.D.

Director, Office of Global Health and Health 

Disparities

National Institute of Neurological Disorders 

and Stroke

National Institutes of Health

Members

Todd Crocco, M.D.

Professor and Director of Pre-Hospital Care 

and Telemedicine

Department of Emergency Medicine

University of Maryland School of Medicine

Glenn Graham, M.D.

Deputy National Director of Neurology

Founder and Executive Director, National 

TeleStroke Program

U.S. Department of Veterans Affairs

Professor of Neurology

University of California, San Francisco School 

of Medicine

Ameer E. Hassan, D.O.

Professor of Neurology

University of Texas Rio Grande Valley

Director, Endovascular Surgical 

Neuroradiology and Clinical Neuroscience 

Research

Valley Baptist Neuroscience Institute

Mary (Lee) E. Jensen, M.D.

Professor Emeritus

Department of Radiology and Medical

Imaging

University of Virginia 

Gaurav Jindal, M.D.

Associate Professor

Department of Diagnostic Radiology and 

Nuclear Medicine

University of Maryland School of Medicine

Becky A. Schierman, M.P.H.

Senior Director 

Clinical Practice & Quality Improvement

American Academy of Neurology 
47

Prehospital Stroke Care Task 

Force 

Co-Chair

Todd Crocco, M.D.

Professor and Director of Pre-Hospital Care 

and Telemedicine

Department of Emergency Medicine

University of Maryland School of Medicine

Members

Ope Adeoye, M.D.

Professor of Emergency Medicine and 

Neurosurgery

Chair, Emergency Medicine Research Division

University of Cincinnati College of Medicine

Brendan Carr, M.D.

Professor and Vice Chair

Department of Emergency Medicine

Associate Dean

Sidney Kimmel Medical College at Thomas 

Jefferson University

Sherita Chapman Smith, M.D.

Assistant Professor

Department of Neurology

University of Virginia Health

Ed Jauch, M.D.

Professor

Department of Emergency Medicine

Director of Acute Stroke Trials

Medical University of South Carolina

Holly Ledyard, M.D.

Associate Professor

Department of Neurology

University of Utah School of Medicine 

Sheryl Martin-Schild, M.D., Ph.D.

Stroke Medical Director

Louisiana Emergency Response Network

President and CEOof Dr. Brain, Inc. 

Medical Director of Neurology and Stroke

New Orleans East Hospital and Touro 

Infirmary

Ashish Panchal, M.D., Ph.D.

Associate Professor of Emergency Medicine

Department of Emergency Medicine

The Ohio State University Wexner Medical 

Center

Chris Richards, M.D.

Assistant Professor of Clinical Emergency 

Medicine

University of Cincinnati College of Medicine

Rafael Rodriquez -Mercado, M.D.

Associate Professor

Director of Endovascular Neurosurgery

University of Puerto Rico School of Medicine

Andy Southerland, M.D.

Distinguished Teaching Associate Professor 

of Neurology and Public Health Sciences

Executive Vice Chair and Residency Program 

Director

Department of Neurology

University of Virginia

Todd Wagner, Ph.D.

Director

Health Economics Resource Center

U.S. Department of Veterans Affairs

Charles Wira, M.D.

Associate Professor

Department of Emergency Medicine

Yale School of Medicine

Yale-New Haven Stroke Program
48

Stacey Quintero-Wolfe, M.D.

Associate Professor

Residency Program Director

Director of Neurointerventional Surgery

Wake Forest School of Medicine
49

Hyperacute and Acute Stroke 

Care Task Force

Co-Chairs

Ameer E. Hassan, D.O.

Professor of Neurology

University of Texas Rio Grande Valley

Director, Endovascular Surgical 

Neuroradiology and Clinical Neuroscience 

Research

Valley Baptist Neuroscience Institute

Mary (Lee) E. Jensen, M.D.

Professor Emeritus

Department of Radiology and Medical 

Imaging

University of Virginia

Members

Ope Adeoye, M.D.

Professor of Emergency Medicine and 

Neurosurgery

Chair, Emergency Medicine Research Division

University of Cincinnati College of Medicine

Brendan Carr, M.D.

Professor and Vice Chair

Department of Emergency Medicine

Associate Dean

Sidney Kimmel Medical College at Thomas 

Jefferson University

Kevin Cockroft, M.D.

Director of Cerebrovascular and 

Endovascular Neurosurgery

Department of Neurosurgery

Penn State Hershey Medical Center

Pennsylvania State University College of 

Medicine 

Mahesh Jayaraman, M.D.

Director, Interventional Neuroradiology

Brown University

Director of Comprehensive Stroke Center 

Neurointerventional Services

Rhode Island Hopital

Tracy Madsen, M.D., Ph.D.

Associate Professor

Department of Emergency Medicine

Brown University

Sheryl Martin-Schild, M.D., Ph.D.

Stroke Medical Director

Louisiana Emergency Response Network

President and CEOof Dr. Brain, Inc

Medical Director of Neurology and Stroke

New Orleans East Hospital and Touro 

Infirmary

Eliza Miller, M.D.

Assistant Professor of Neurology

Department of Neurology

Columbia University

Rafael Rodriguez-Mercado, M.D.

Associate Professor

Director of Endovascular Neurosurgery

University of Puerto Rico School of Medicine

Anjail Sharrief, M.D., M.P.H. 

Associate Professor of Neurology

Director of Stroke Prevention, Institute of 

Stroke and Cerebrovascular Disease

University of Texas Health McGovern Medical 

School

Andrew Southerland, M.D.

Distinguished Teaching Associate Professor 

of Neurology and Public Health Sciences

Executive Vice Chair and Residency Program 

Director

Department of Neurology

University of Virginia
50

Prasanna Tadi, M.D.

Assistant Professor

Department of Neurology

Creighton University School of Medicine

Venu Vadlamudi, M.D.

Associate Professor of Radiology

University of Tennessee Health Science Center

Medical Director, Stroke and Cerebrovascular Disease Program

Inova Alexandria Hospital (2020-2021)

Charles Wira, M.D.

Associate Professor

Department of Emergency Medicine

Yale School of Medicine

Yale-New Haven Stroke Program
51

Inpatient Stroke Care Task 

Force

Co-Chairs

Karen Furie, M.D., M.P.H.

Professor and Chair

Department of Neurology

Warren Alpert Medical School at Brown 

University

Lawrence R. Wechsler, M.D.

Professor and Chair

Department of Neurology

Perelman School of Medicine at the University 

of Pennsylvania

Members

Aaron Anderson, M.D.

Assistant Professor

Vice-Chair Diversity, Equity, and Inclusion

Department of Neurology 

Emory University School of Medicine

Karen Albright, D.O., Ph.D., M.P.H.

Associate Professor

Departments of Neurology and Pharmacology

State University of New York Upstate Medical 

University

Justin Caplan, M.D.

Assistant Professor of Neurological Surgery

Department of Neurological Surgery

Johns Hopkins University School of Medicine

Sherita Chapman Smith, M.D.

Assistant Professor

Department of Neurology

University of Virginia Health

Prasanna Tadi, M.D.

Assistant Professor

Department of Neurology

Creighton University School of Medicine

Michael Mullen, M.D.

Associate Professor

Lewis Katz School of Medicine at Temple 

University

Director, Stroke Program

Temple University Hospital

Sandra Narayanan, M.D.

Vascular and Interventional Neurologist

Pacific Neuroscience Institute

Director, Neurointerventional Program

Providence Saint Joseph Medical Center

Associate Professor

Departments of Neurology and Neurological 

Surgery

University of Pittsburgh Medical Center 

(2019-2022)

Soojin Park, M.D.

Associate Professor

Department of Neurology

Columbia University Vagelos College of 

Physicians and Surgeons

Babu Welch, M.D.

Professor of Neurosurgery and Radiology

Director of the University of Texas 

Southwestern Microvascular Laboratory

University of Texas Southwestern Medical 

Center

Shadi Yaghi, M.D.

Associate Professor

Department of Neurology

Warren Alpert Medical School at Brown 

University

Co-Director, Comprehensive Stroke Center

Rhode Island Hospital
52

Appendix D: Acronyms and Abbreviations

AAN American Academy of Neurology

ACGME Accreditation Council for Graduate Medical Education 

AHA American Heart Association

AHORA Andar, Hablar, Ojos, Rostro, and Ambos Brazos o Piernas

ALS advanced life support 

ASA American Stroke Association

BE-FAST Balance, Eyes, Face, Arm, Speech, and Time

CDC Centers for Disease Control and Prevention

CI confidence interval

CME continuing medical education

CMS Centers for Medicare & Medicaid Services

COVID-19 coronavirus disease 2019

CSC Comprehensive Stroke Center

CT computed tomography 

CTA CT angiography

DEI Diversity, Equity, and Inclusion 

DVT deep venous thrombosis

ED emergency department

EM emergency medicine 

EMS emergency medical services 

EMT emergency medical technician

ESO Electronic Health Records for Emergency Services

ET3 model Emergency Triage, Treat, and Transport Model

EVT endovascular thrombectomy 

FAST Act Fixing America's Surface Transportation Act
53

FAST Face, Arm, Speech, Time

FL Florida

GWTG program Get with the Guidelines program

HIT health information technology 

ICD International Classification of Diseases (ICD)

ICM implantable cardiac monitor 

IV tPA intravenous tissue-type plasminogen activator

JAMA Journal of the American Medical Association

LRP loan repayment program

LVO large vessel occlusion

MEDPAR Medicare Provider Analysis and Review database

MIST Mobile Interventional Stroke Team 

MRI magnetic resonance imaging 

NEMSIS National EMS Information System

NIH National Institutes of Health

NINDS National Institute of Neurological Disorders and Stroke

NQF National Quality Forum 

nSES neighborhood socioeconomic status 

OR odds ratio

PCP primary care physician 

PR Puerto Rico

PSC primary stroke center

RÁPIDO Rostro caído, Alteración del equilibrio, Pérdida de fuerza, Impedimento visual, 

Dificultad para hablar, Obtenga ayuda rápido

REGARDS study REasons for Geographic And Racial Differences in Stroke Study

SES socioeconomic status 

STEMI ST-elevation myocardial infarction 
54

TIA transient ischemic attack

tPA tissue plasminogen Activator 

TSC thrombectomy capable stroke center

US United States

VA U.S. Department of Veterans Affairs
55

Appendix E: Acknowledgements

The steering committee would like to thank the sponsor, the National Institute of Neurological 

Disorders and Stroke, part of the National Institutes of Health (NIH), for its decades of work in 

stroke research and for its leadership and facilitation in the development of this report. The 

committee also wishes to express our gratitude for the symposium speakers, participants, and 

many other individuals who shared their ideas, experiences, and expertise throughout the study. 

These insights were invaluable to developing the report.

We would like to thank other members of the committee—Todd Crocco, Mary Jensen, Gaurav Jindal, 

Glenn Graham, Ameer Hassan, Becky Schierman—and task forces for working together to ensure a 

lively and successful symposium and analysis. We would also like to acknowledge the input of the 

Centers for Disease Control and Prevention as symposium participants and collaborators. The 

committee is grateful for the many staff at the NIH who provided support for symposium planning 

and report development. Special thanks are extended to Samantha White and Andrea Varea, who 

orchestrated and facilitated work for the symposium and report; Diana Andriola, Ryan Calabrese, 

Jenny Kim, Mara Olenik, and Carlo Quintanilla, who facilitated task force meetings; and Nina 

Lichtenberg and Carlo Quintanilla, for their editorial assistance provided in preparing the report. 

Notably, most of the study into inequities in access to stroke care, including running the public 

symposium and composing the report, took place during the COVID-19 pandemic. This historic,

global event was particularly challenging for those in medical, healthcare, and public health

professions. We are greatly appreciative of individuals’ timeand dedication to this effort.