Citation: Fulmer, E.B.; Keener Mast, D.; Godoy Garraza, L.; Gilchrist, S.; Rasool, A.; Xu, Y.; Brown, A.; Omeaku, N.; Ye, Z.; Donald, B.; et al. Impact of State Stroke Systems of Care Laws on Stroke Outcomes. Healthcare 2023, 11, 2842. https:// doi.org/10.3390/healthcare11212842 Academic Editor: Stephen M. Modell Received: 16 August 2023 Revised: 24 October 2023 Accepted: 24 October 2023 Published: 28 October 2023 Copyright: © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). healthcare Article Impact of State Stroke Systems of Care Laws on Stroke Outcomes Erika B. Fulmer 1, * , Dana Keener Mast 2 , Lucas Godoy Garraza 2 , Siobhan Gilchrist 3 , Aysha Rasool 1,4 , Ye Xu 2 , Amanda Brown 3 , Nina Omeaku 3 , Zhiqiu Ye 1 , Bruce Donald 3 , Sharada Shantharam 1 , Sallyann Coleman King 1 , Adebola Popoola 1 and Kristen Cincotta 2 1 Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop MS-S107-1, Atlanta, GA 30341, USA; aysharasool@outlook.com (A.R.); sophieye999@gmail.com (Z.Y.); ktq4@cdc.gov (S.S.); fjq9@cdc.gov (S.C.K.); nci9@cdc.gov (A.P.) 2 ICF, 1902 Reston Metro Plaza, Reston, VA 20190, USA; dana.keenermast@icf.com (D.K.M.); lucas.godoygarraza@icf.com (L.G.G.); ye.xu@icf.com (Y.X.); kristen.cincotta@icf.com (K.C.) 3 ASRT, Inc., 4158 Onslow Place SE, Smyrna, GA 30080, USA; sgilchrist@mitre.org (S.G.); vsw7@cdc.gov (A.B.); yom4@cdc.gov (N.O.); qsq3@cdc.gov (B.D.) 4 Oak Ridge Institute for Science and Education, P.O. Box 117, Oak Ridge, TN 37831-0117, USA * Correspondence: duj2@cdc.gov; Tel.: +1-770-488-5334 Abstract: Since 2003, 38 US states and Washington, DC have adopted legislation and/or regulations to strengthen stroke systems of care (SSOCs). This study estimated the impact of SSOC laws on stroke outcomes. We used a coded legal dataset of 50 states and DC SSOC laws (years 2003–2018), national stroke accreditation information (years 1997–2018), data from the Healthcare Cost and Utilization Project (years 2012–2018), and National Vital Statistics System (years 1979–2019). We applied a natural experimental design paired with longitudinal modeling to estimate the impact of having one or more SSOC policies in effect on outcomes. On average, states with one or more SSOC policies in effect achieved better access to primary stroke centers (PSCs) than expected without SSOC policies (ranging from 2.7 to 8.0 percentage points (PP) higher), lower inpatient hospital costs (USD 610–1724 less per hospital stay), lower age-adjusted stroke mortality (1.0–1.6 fewer annual deaths per 100,000), a higher proportion of stroke patients with brain imaging results within 45 min of emergency department arrival (3.6–5.0 PP higher), and, in some states, lower in-hospital stroke mortality (5 fewer deaths per 1000). Findings were mixed for some outcomes and there was limited evidence of model fit for others. No effect was observed in racial and/or rural disparities in stroke mortality. Keywords: stroke systems of care; law; health policy; public health; legal epidemiology; stroke out comes 1. Introduction In 2020, stroke was identified as the fifth leading cause of death in the United States (US), accounting for over 160,000 deaths [1]. Stroke is a leading cause of long-term disability in the US and results in nearly USD 57 billion in medical expenses, including direct medical costs and indirect costs from premature mortality [2]. Lifesaving, disability-reducing treatments are available for stroke. However, to be effective, patients must receive care within the first hours of stroke onset [3]. Public health practitioners can create a supportive infrastructure for ensuring that stroke patients have time-sensitive access to lifesaving treatments. Comprehensive stroke systems of care (SSOCs) are integrated networks (often coordinated at state and/or re- gional levels) helping stroke patients receive the most appropriate and timely treatment [3]. SSOCs are designed to support and enhance all phases of stroke care including prehos- pital identification, ambulance transport, stroke center certification, in-hospital diagnosis Healthcare 2023, 11, 2842. https://doi.org/10.3390/healthcare11212842 https://www.mdpi.com/journal/healthcare