Stroke Center Certification and Within-Hospital Racial Disparities in Treatment

Importance: Despite improvements in access to stroke technology, it remains unclear whether Black and White patients with stroke experience similar benefits after a hospital becomes stroke certified and whether stroke center expansion has changed disparities between Black and White patients over time. Objective: To examine the association of hospital stroke center certification with receipt of acute ischemic stroke treatments and health outcomes between Black and White patients with stroke. Design, Setting, and Participants: This cohort study implemented a linear probability model with hospital fixed effects to evaluate changes in outcomes for Black and White patients, comparing outcomes before and after a hospital was certified as a stroke center (treatment group) relative to changes in outcomes at hospitals that did not acquire stroke certification (control group). Participants included patients with acute ischemic stroke who were covered by Medicare fee-for-service, who lived in urban communities, and who were admitted to hospitals between January 1, 2009, and December 31, 2019. Data were analyzed from September 1, 2024, to April 30, 2025. Exposure: Admission to a certified stroke center. Main Outcomes and Measures: Probability of (1) receipt of thrombolytic therapy, (2) receipt of mechanical thrombectomy, and (3) being home at 90 days and (4) 1-year mortality. Results: Among 2 109 075 million admissions of patients with stroke included in the analysis, 15.3% were Black, 84.7% were White, 56.8% were female, 15.3% were 65 to 69 years of age, 16.4% were 70 to 74 years of age, 17.7% were 75 to 79 years of age, 18.8% were 80 to 84 years of age, and 31.9% were 85 years or older. Among White patients, the probability of receiving thrombolytic therapy increased by 1.70 (95% CI, 1.19-2.21) percentage points when a hospital became a primary stroke center (PSC) and 3.76 (95% CI, 2.89-4.62) percentage points when a hospital became a thrombectomy-capable or comprehensive stroke center (TSC or CSC), relative to White patients at non-stroke-certified hospitals. Among Black patients, the probability of receiving thrombolytic therapy did not change when admitted to a new PSC or a new TSC or CSC compared with Black patients at non-stroke-certified hospitals. For thrombectomy, a new TSC or CSC was associated with an increase of 3.74 (95% CI, 3.02-4.45) percentage points for White patients and 0.97 (95% CI, 0.03-1.90) for Black patients. No improvements in being home at 90 days or in 1-year mortality were observed. Conclusions and Relevance: In this cohort study, the likelihood of receiving stroke treatments increased for White but not Black patients within the same facility after the center was stroke certified as a PSC or a TSC or CSC. These within-hospital racial differences serve as sobering evidence that racial disparities in stroke care persist despite increased access to care.