Acute stroke care coordination in the United States: Variation in state laws for Emergency Medical Services and hospitals

Background: Lack of care coordination between Emergency Medical Services (EMS) and hospitals contributes to delay of acute stroke (AS) treatment. In the United States, states have adopted laws to improve the quality of EMS and hospital care; the degree to which these laws create regulatory incentives to promote care coordination between them is less well known. We examined state variation in attributes of laws that may influence AS care coordination between EMS and hospitals. Materials and Methods: We selected ten law "dyads" across seven domains of EMS and hospital AS care informed by published risk assessments of critical steps for improved door-to-needle time and door-in-door-out time. We assessed concordance in prescriptiveness (degree to which levels were similar) and in adoption (degree to which laws were adopted concurrently) of the laws in effect between January 2002 and January 2018 in the United States. Results: The proportion of states with prescriptiveness concordance ranged from 47 % (e.g., inter-facility transfer agreements, comprehensive, primary stroke center certification) to 75 % (e.g., Continuous Quality Improvement (CQI) for EMS and hospitals). Adoption concordance ranged from 31 % (e.g., inter-facility transfer agreements, Acute Stroke Ready Hospital certification) to 86 % (e.g., CQI for EMS and hospitals). Laws for EMS triage were less prescriptive than laws for stroke center certification in 22 %-35 % of states adopting both laws, depending on stroke center type. Conclusions: Subsequent policy implementation and impact studies may benefit from assessing concordance and prescriptiveness in policy intervention adoption, particularly as a foundation for evaluating delays in AS treatment due to inefficient care coordination.