Do primary stroke centers occur randomly?

W hen the Brain Attack Coalition began to publish recommendations for the development of Stroke Centers, they chose to begin with primary stroke centers (PSCs), in the hope that such centers would impact the largest number of patients in the shortest period of time. 1,2 Currently, in the United States, there are >1000 PSCs certified by the Joint Commission, and likely several hundred more certified by other private agencies (ie, Healthcare Facilities Accreditation Program and Det Norske Veritas), as well as some state health departments. Considering there are slightly >5000 acute care hospitals in the country, this means that ≈25% of hospitals in the United States are a PSC. This represents a significant advance in stroke care over a little more than a decade since the Joint Commission began their PSC certification program. As McDonald and colleagues note, 3 PSCs are associated with many improved important outcomes (reduced death and disability, higher rates of utilization of intravenous tissue-type plasminogen activator), as well as better compliance with several other stroke care measures as tracked by Get with the Guidelines-Stroke. It is now common, if not routine, for some cities and some regional emergency medical service providers to divert patients with a suspected acute stroke to the nearest PSC or Comprehensive Stroke Center. 6,7 Emergency medical services routing to PSCs may also be a factor in motivating some hospitals to become a PSC so that they do not get bypassed. 8 When the Brain Attack Coalition first published guidelines for PSCs, 1 there were concerns about if and how hospitals within a city or region would allocate resources and compete to become a PSC. These concerns were largely unfounded because most medium and large urban areas now have several certified PSCs that compete for patients. Even small urban areas often have one or more PSCs. This is likely a positive development because patients now have many options for acute stroke care in most cities, giving them freedom to choose the care facility that is best for them (to the extent that they have a choice in the matter). It also means that stroke care in many cities has improved to the extent that it now supports several hospitals that meet the various criteria to become a PSC. Of course the PSC cannot be viewed in isolation; it is one component of a larger and more complex Stroke System of Care, which now …