摘要：Objectives. We identified barriers and facilitators to the state-level implementation of primary stroke center (PSC) policies, which encourage the certification or designation of specialized stroke treatment facilities and may address concerns such as transportation bypass, telemedicine, and treatment protocols. Methods. We studied the experiences of 4 states (Florida, Massachusetts, New Mexico, and New York) selected from the 18 states that had enacted PSC policies or were actively considering doing so. We conducted semistructured interviews during fieldwork in each case study state. Results. Our results showed that system fragmentation, gaps in human and financial resources, and complexity at the interorganizational and operational levels are common barriers and that policy champions, stakeholder support and communication, and operational adaptation are essential facilitators in the adoption and implementation of PSC policies. Conclusions. The identification of barriers and facilitators reveals the contextual elements that can help or hinder policy implementation and may be useful in informing policy formulation and implementation in other jurisdictions. Proactively identifying jurisdictional challenges and opportunities may help facilitate the policy process for PSC designation and allow jurisdictions to develop more effective stroke systems of care. Stroke is the third leading cause of death and the leading cause of long-term disability in the United States. Direct and indirect costs for stroke were estimated to reach $73.7 billion in 2010. 1 Despite the knowledge advances of the past few decades for stroke prevention, treatment, and rehabilitation strategies, 2 only a small percentage of individuals experiencing stroke symptoms receive the recommended treatment in the crucial hours after symptom onset. Barriers to securing timely and effective treatment include the lack of public awareness of stroke symptoms and the need for timely treatment, as well as the logistical and coordinative challenges of providing appropriate treatment within the narrow window of opportunity after a stroke attack. Inadequate coordination of the various professionals involved in stroke care, such as 911 responders, emergency medical services staff, hospital emergency department staff, and acute stroke care team members in hospitals, exacerbates the problem. 3 – 5 To better coordinate the fundamental components of stroke care, The American Heart Association and American Stroke Association (AHA–ASA) recommends establishing “stroke systems of care.” 2 The AHA–ASA recommendation draws from an Institute of Medicine emphasis on coordinating systems of care to integrate prevention, treatment, and patient access to evidence-based practice. The Institute of Medicine recommendation comes from an observation that when different essential elements of stroke care, especially during the crucial prehospital period, occur in isolation from one another, the quality and effectiveness of the care is compromised. 6 One rationale for establishing stroke systems of care is to ensure that all patients having signs or symptoms of stroke are transported to a facility that is capable of evaluation and treatment. 2 An example of an appropriate treatment facility is a Joint Commission–certified primary stroke center (PSC). PSC will be used as a general term for stroke-ready facilities, because we recognize a variability across states on certification and designation terminology. In addition, other state-specific models recognize stroke-ready facilities. Optimal treatment of stroke depends on the recognition of sometimes subtle symptoms and rapid access to stroke-ready facilities that are capable of administering appropriate treatment, regardless of certification. Transporting a patient to a PSC can facilitate rapid evaluation of and treatment of acute stroke patients and improve patient outcomes. 2 , 7 In the past 5 years, several states have proposed, adopted, and implemented policies that encourage certification and designation of PSCs. The detail and scope of these policies vary across states. Similarly, state policies vary regarding the implementation of such policies. The experiences of states with PSC policy are not well documented. Through a collaborative project between the US Centers for Disease Control and Prevention's Division for Heart Disease and Stroke Prevention and the National Association of Chronic Disease Directors, we studied the variability of PSC policy development and implementation within and between states, identifying key elements of successful PSC policy implementation, including the barriers and facilitators to PSC policy implementation based on the experience of 4 case study states.
