1. Core Elements of Stroke Systems of Care

Recommendations and/or Clinical Considerations

1.0 Structure of Stroke Systems of Care

All regions in Canada should have integrated and coordinated systems in place to ensure individuals with stroke receive timely acute stroke care and ongoing management to optimize recovery and outcomes [Strong recommendation; Moderate quality of evidence].
A stroke system should support local and regional educational initiatives to increase stroke awareness (including stroke warning signs, risk factors, primary and secondary prevention, and recovery), aimed at the general population with enriched targeting of populations at increased risk for stroke and poor outcomes after stroke [Strong recommendation; Moderate quality of evidence].
A stroke system should monitor the effectiveness of community education in improving behavioral responses to signs of stroke, stroke treatment rates, mortality, and other relevant outcomes [Strong recommendation; Moderate quality of evidence].
A stroke system should support communities and providers in initiating prevention programs and services applicable to broad populations [Strong recommendation; Moderate quality of evidence].

1.1 Core Elements of a Stroke System

Organized and integrated stroke systems of care should be established and sustained with continuous quality improvement in every health region in Canada [Strong recommendation; Moderate quality of evidence].
Components of an integrated stroke system should include:
1. Leaderships and partnerships established in each region, including an oversight committee and coordinating body with interdisciplinary representation to oversee stroke systems [Strong recommendation; Low quality of evidence].
2. Public awareness and education about the signs of stroke and actions to take [Strong recommendation; Moderate quality of evidence]. Refer to Section 2 of this module for additional information.
3. Strategies and processes that are collaborative, co-developed and inclusive should be in place to identify and purposely address the needs of specific populations disproportionately impacted by health inequities and/or who face increased barriers to accessing care, such as Indigenous, South-Asian and Black populations, newcomers to Canada, and gender-diverse and 2SLBGTQIA+ communities [Strong recommendation; Moderate quality of evidence].
4. Primary prevention strategies should be in place to screen those at highest risk for stroke using validated tools, clearly identifying lines of responsibility and appropriate time points (such as at periodic health exams, prenatal visits) [Strong recommendation; Moderate quality of evidence]. Note: additional guidance on primary prevention of cardiovascular risk factors is out of scope for this set of recommendations.
5. Implementation mechanisms to support primary prevention treatment regimens [Strong recommendation; Moderate quality of evidence].
6. Public emergency response system (e.g., 911) with specific protocols for stroke [Strong recommendation; Moderate quality of evidence]. Refer to the CSBPR Acute Stroke Management Module, Section 3 for additional information on emergency medical systems for stroke.⁷
7. Emergency medical systems transport protocols and bypass agreements should be in place to ensure rapid access to closest most appropriate hospital with acute stroke management capability [Strong recommendation; Moderate quality of evidence]. Refer to the CSBPR Acute Stroke Management Module, Section 3 for additional information.⁷
8. A defined network of acute care hospitals that includes sites with emergent acute stroke management capability (comprehensive stroke centres and or district/secondary centres), including access to vascular imaging, acute thrombolysis, endovascular therapy, acute stroke, cerebrovascular surgery, and standardized inpatient protocols [Strong recommendation; High quality of evidence]. Note, within the Canadian Stroke strategy, every hospital in Canada has been categorized within one of five levels of acute stroke management capability, ranging from full service comprehensive stroke centres (Level 5) to small remote and rural centres that do not have a CT scanner on premises (Level 1). Refer to the CSBPR Acute Stroke Management Module, Figure 2 for a detailed figure describing the criteria for each acute stroke management service level. ⁷
9. Designated interprofessional team members with expertise and training in stroke management across each part of the continuum of care [Strong recommendation; Moderate quality of evidence].
10. Interprofessional care planning and effective communication to ensure continuity of care, safety, and to reduce risk of complications and adverse events during stroke care particularly at transition points [Strong recommendation; Low quality of evidence]. Refer to Section 3 of this module for additional information.
11. Stroke rehabilitation services that are able to meet individual care needs and goals in a timely basis [Strong recommendation; High quality of evidence]. Refer to the CSBPR Rehabilitation, Recovery and Community Participation following Stroke modules, Part One, Part Two and Part Three, for additional information.^{7, 8, 76}
12. Stroke prevention clinics (or similar vascular prevention clinics, services or models of care) that use standardized and evidence based referral processes to provide a comprehensive interdisciplinary approach to prevention of first or recurrent stroke, conduct detailed assessments by a range of healthcare disciplines and across specialties, facilitate timely access to appropriate diagnostic testing and interventions, and provide education to individuals and families [Strong recommendation; High quality of evidence]. Refer to the CSBPR Secondary Prevention of Stroke module for additional information.⁶
13. Mechanisms to promote continuity of care between acute care facilities, rehabilitation, prevention and community services, the individual with stroke, their family and caregivers, and primary care providers [Strong recommendation; Moderate quality of evidence].
14. Seamless and timely information flow with integrated clinical information systems across settings and care providers that enable rapid access to medical information to facilitate timely care, continuity, and safe transitions of care [Strong recommendation; Moderate quality of evidence]. Refer to Section 3 of this module for additional information.
15. Programs and services that raise awareness of, and assist in the management of mental health, psychosocial and emotional needs for individuals with stroke, their families and caregivers at all stages across the continuum of care [Strong recommendation; Moderate quality of evidence]. Refer to the CSBPR Rehabilitation, Recovery and Community Participation following Stroke module, Part Three, Section 1 for additional information.⁹
16. Organized community services and accessible resources to support optimum recovery, adaptation, and community participation (social, leisure); including access to supports and services at home to meet the individual needs of individuals with stroke and their family and caregivers [Strong recommendation; Moderate quality of evidence]. Refer to the CSBPR Rehabilitation, Recovery and Community Participation following Stroke module, Part Three for additional information.⁹
17. Longterm care/housing protocols, policies and staff training to facilitate access and effective stroke management that support ongoing individual needs following stroke. These should optimize the individual’s quality of life by addressing continued rehabilitation needs, meaningful participation, and ensuring access to clinicians with stroke knowledge and expertise [Strong recommendation; Moderate quality of evidence]. Refer to Section 7 of this module for additional information.
18. Ongoing medical follow-up with primary care and other services for individuals in the community appropriate to their unique needs, which may address evaluating progress of recovery, preventing deterioration, maximizing functional and psychosocial outcomes, preventing stroke recurrence, and improving quality of life [Strong recommendation; Moderate quality of evidence].
19. Advance care planning, end of life, palliative care and MAiD support and services in place across the continuum [Strong recommendation; Moderate quality of evidence]. Refer to Section 8 and Section 9 of this module for additional information.
20. Virtual stroke care services that enhance access and capacity through the integration of virtual technologies for assessment, treatment and care delivery [Strong recommendation; Moderate quality of evidence]. Refer to Section 4 of this module for additional information.
21. Data monitoring systems to collect and monitor health system performance and outcomes, effectiveness, appropriateness and equity, to inform ongoing care delivery and future planning, including standardized reporting to enable continuous surveillance and improvement [Strong recommendation; Moderate quality of evidence].
22. Education and training in shared decision-making skills and strategies for all healthcare professionals, individuals with stroke, families, and caregivers [Strong recommendation; Moderate quality of evidence]. Refer to Section 5 of this module for additional information.

Section 1 Clinical Considerations

Stroke systems of care should be designed to ensure equitable access to healthcare services for all individuals, regardless of race, ethnicity, gender, socioeconomic status, geographic location, disability, sexual orientation, or other social determinants of health. All facilities delivering care for individuals with stroke should proactively identify and address barriers to care, implement culturally and linguistically appropriate services, and integrate equity-focused strategies into quality improvement initiatives to promote fair and just health outcomes for all individual populations.
Healthcare systems are under considerable stress and access to services may be driven by capacity and resourcing, resulting in unjustified variations between centres. It is important to ensure that systems are in place to optimize access to the right care regardless of where an individual is geographically located at the time their stroke occurs.
Time sensitive care also extends beyond acute stroke management to the full continuum including access to rehabilitation and recovery care, secondary prevention services, as well as community and long-term care supports.
Interprovincial and interregional collaboration in place to develop processes to increase access to services and resources where they may not be available in an individual region or province.

Worldwide, stroke is a leading cause of death and disability. Every year, over 108,000 strokes occur in Canada. ² Stroke is a leading cause of adult disability, with 969,000 individuals estimated to be living with the effects of stroke in Canada in 2022/23. ³ The lifetime risk of stroke has also increased over the last 20 years by 50% and is now one in four individuals. ²³ Projections of stroke burden up to 2050 are estimated to include 21.43 million stroke cases globally, 159.31 million survivors, 12.05 million deaths, and 224.86 million disability‐adjusted life years due to stroke.²⁴ The public health implications and significant financial burden of these projections, highlight the urgent need for effective, integrated accessible, equitable and affordable coordinated systems of stroke care. In 2004 the Canadian Stroke Strategy (CSS) was launched, calling on every province and territory in Canada to build an integrated approach to stroke care from public awareness through emergent and acute care, rehabilitation, prevention, and long-term recovery, and end-of-life care. The national CSS leadership provided tools and resources to support provincial, territorial, and regional efforts including the Canadian Stroke Best Practice Recommendations, signs of stroke campaigns, performance measures and active data collection mechanisms. Each province, territory and region has evolved access and quality of stroke services at different paces, and vary based on available leadership, funding, capacity, and resources.

Integrated and coordinated stroke systems of care, established locally, regionally and provincially/territorially have been shown to optimize timely access to care, increase equity and reduce disparities in access to stroke services across the continuum, optimize outcomes and better meet the needs of individuals with stroke, their family and caregivers. Healthcare providers and system leaders must work collaboratively with effective communication to ensure continuity of care for individuals with stroke and their families as they transition from one phase and setting of care to the next. Health equity is a foundational principle of high-quality healthcare. Disparities in access can lead to poorer health outcomes and perpetuate systemic inequalities. By embedding equity into clinical practice, healthcare systems uphold ethical standards, enhance individual trust and satisfaction, and contribute to the reduction of health disparities.

Individuals with lived experience of stroke describe navigating the stroke care system as complex and at times, challenging. They emphasize that the time following a stroke can be difficult and confusing for the individual with stroke as well as their family and caregivers, making navigating the system that much harder. They further stress that the system can be made more difficult to navigate because of such factors as accessibility and availability of local support services, services that are not provided in a preferred language, services that are not culturally sensitive, relevant and appropriate and communication challenges that exist across the continuum of care. The importance of considering sex/gender differences in stroke care is also highlighted, as part of providing person-centred care. They encourage healthcare providers to work collaboratively with the individual with stroke, family and caregivers in stroke system planning and care delivery.

System Implications +-

To ensure individuals experiencing a stroke receive timely stroke assessments, interventions and management, interdisciplinary teams need to have the infrastructure and resources required. These may include the following components established at a systems level.

Stroke systems of care are recognized as a priority program in all provinces and territories with appropriate dedicated funding and human resource planning.
Coordination and collaboration among healthcare partners across the continuum to deliver seamless and timely care.
Elimination of siloes within healthcare services to increase efficiency and enable individuals with stroke to access needed services in a timely way.
Stroke systems have dedicated leadership and governance responsible for leading and coordinating acute, rehabilitation and recovery stroke services across the stroke system of care.
The health system engages with urban and rural populations to understand and identify barriers that prevent their timely access to coordinated acute and rehabilitation stroke services (AC standards).
Conduct regular assessments to identify gaps in stroke care access and outcomes across the continuum.
Provide staff training on implicit bias, cultural responsiveness, and health equity.
Processes for incorporating individual circumstances, such as social determinants of health, into stroke clinical workflows.
Engage with communities to co-design solutions that address local access barriers to stroke services across the continuum of care.
The development and implementation of an equitable and universal pharmacare program, implemented in partnership with the provinces, designed to improve access to cost-effective medicines for all individuals in Canada regardless of geography, age, or ability to pay. This program should include a robust common formulary for which the public payer is the first payer.

Performance Measures +-

System indicators

The number and proportion of acute care hospitals participating in a regional or provincial stroke network.
The proportion of all hospitals in a province affiliated with a secondary or tertiary stroke centre that provides acute stroke treatment.
The presence of an integrated evidence-driven emergency medical services stroke alert and response system in each region.
Proportion of the population who live within 4.5, 6 and 24 hours by ground transportation of an acute stroke-enabled hospital (I.e., CSBPR stroke services level 3, 4, or 5; with CT scanner on-site and ability to deliver intravenous thrombolysis).
The number and proportion of geographic regions in Canada with access to stroke neurology, neurosurgical, neurointerventional and stroke rehabilitation clinical experts within guideline informed timelines to access required stroke care.
The number and proportion of stroke centres regularly submitting data to a stroke quality improvement database which is regularly accessed to inform planning and care delivery.
The amount of research funding directed towards stroke annually across Canada.
Number of stroke centres that actively participate in clinical stroke research trials annually.
Proportion of stroke centres operating with a broad team of interdisciplinary stroke expert healthcare professionals; and the proportion with extended vacancies or gaps in expertise.
Availability and use of stroke clinical pathways/protocols across stroke centres, aligned to the CSBPR modules (e.g., EMS triage and transportation, initial emergency assessment and imaging, intravenous thrombolysis, stroke unit care, rehabilitation assessments).

Process indicators

Time from publication to integration of new technologies and therapies for stroke (e.g., late window thrombolysis, wearable monitoring) into care pathways.
Staff participation in continuous professional development related to stroke.
Proportion of stroke centres in Canada with a designated stroke coordinator or system navigator.

Person-oriented outcome and experience indicators

Proportion of individuals with stroke enrolled in stroke research studies in Canada annually among centres actively engaged in research.
Quality of life of individuals after discharge for an acute stroke event, measured at transition points and routinely throughout recovery (for example, at 60, 90, 180 days and 1 year following discharge).

Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Healthcare Provider Information

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List 1

In Canada, there is no national legislation specifically mandating or regulating stroke systems of care, unlike in some countries where legislation explicitly governs stroke networks. However, stroke systems of care are strongly supported through national frameworks, provincial health authorities, and evidence-based clinical guidelines. Key governance mechanisms include 1) the Canadian Stroke Best Practice Recommendations (CSBPR), 2) provincial and territorial stroke strategies, such as the Ontario Stroke System (Ontario Health) and the Alberta Stroke Program, which coordinate stroke care delivery, regional stroke centres, EMS protocols, and quality improvement initiatives, 3) standardized performance measurement frameworks and data monitoring mechanisms, such as CIHI stroke special projects, 4) Accreditation Canada, whereby hospitals, whose participation is voluntary, are assessed on their adherence to best practices, and 5) EMS bypass protocols that support stroke-specific bypass protocols, ensuring individual with stroke are transported to facilities with appropriate levels of care (e.g., PSC or CSC).

A clearly defined network of acute care hospitals is essential for the delivery of timely and effective stroke care. In Canada, the network includes 1) comprehensive stroke centres (CSC, n=42), which provide advanced neuroimaging (CT/MRI, perfusion, angiography), 24/7 endovascular thrombectomy (EVT) services, neurosurgery and neurocritical care, acute stroke units, rehabilitation, and secondary prevention, 2) Primary Stroke Centres (PSCs), which can deliver emergent stroke care, including 24/7 access to CT imaging and interpretation, intravenous thrombolysis, and can admit individual with stroke to an acute stroke unit or designated stroke beds. In PSCs, individual with stroke requiring EVT or neurosurgical intervention may be transferred to a CSC, and 3) District Stroke Centres (DSCs), capable of proving an initial assessment and stabilization, particularly in rural or smaller communities, but which may not have full imaging or thrombolysis capability but are integrated within a stroke referral network with EMS bypass protocols and telemedicine support.

An ideal stroke system of care is defined as one that is comprehensive, diverse and longitudinal, one that addresses all aspects of stroke care within an integrated, organized and coordinated approach. A stroke system spans the continuum of care from primary prevention to end of life and is composed of many components. Specific key elements of an acute system include the provision of care on a stroke unit, the availability of CT or MRI and carotid doppler imaging for individual with stroke, and access to neurosurgical services. The ideal system also incorporates performance monitoring, continuous quality improvement, and structured transitions from acute care to rehabilitation and long-term recovery, with a focus on secondary prevention and community reintegration. The benefit of the application of this bundle of acute stroke services was examined in a retrospective study including data from 319,972 individuals hospitalized for stroke/transient ischemic attack (TIA) in Canada over a 10-year period (2003/04 to 2013/14). Provinces with integrated stroke care systems were identified using pre-specified criteria. The adjusted incidence rate ratio for 30-day mortality was 0.96 (95% confidence interval [CI] 0.89–1.04) was significantly lower for provinces with integrated systems of stroke care (British Columbia, Alberta, Ontario, Quebec, Nova Scotia, and Prince Edward Island) compared with those without such systems.⁴ In a systematic review including the results from 99 studies, Eustace et al.²⁵ reported that integrated stroke care was associated with significantly reduced risk of recurrent stroke (relative risk [RR]=0.79, 95% CI 0.63–1.00), significant improvements in quality of life (standardized mean difference [SMD]=0.41, 95% CI 0.26–0.56), and a reduced incidence of depression (RR= 0.95, 95% CI 0.92–0.99), with no significant reductions in mortality (at 90 days, one year or >one year), major bleeding or unplanned readmissions. Interventions assessed within the individual studies were wide ranging. Examples included screening for complications, quality of life, and depression, counselling for lifestyle changes, secondary prevention counselling, medication adherence, interviews and education (web-based training) for caregivers and individual with stroke, standardized care pathway, very early mobilisation, early supported discharge, telerehabilitation exercise, individualised transitional care model based at home, patient/family education, and an interdisciplinary poststroke consultation team, among others.

In another systematic review including the results of 19 RCTs, Liu et al. ²⁶ examined the effectiveness of stroke-specific integrated care (IC) models defined by 10 core principles, in comparison to conventional care. Examples of interventions included very early supported discharge programs, a virtual interdisciplinary stroke care clinic, integrated palliative care, an integrated interdisciplinary geriatric rehabilitation programme, stroke secondary prevention, combining hospital and community resources, an integrated primary care management programme, and a transitional care program for individuals with strokes. Integrated care was associated with significant improvements in health-related quality of life (SMD= 0.69, 95% CI 0.35 to 1.02), activities of daily living performance (SMD=0.95, 95% CI 0.48 to 1.43) and depression (SMD=-1.02, 95% CI -1.77 to -0.26).

Public awareness and emergency response are important components of stroke systems, as early recognition of symptoms and timely response can significantly reduce stroke-related disability and death. Since 2014, the Heart & Stroke Foundation of Canada has led a nationwide FAST (Face, Arm, Speech, Time) campaign to improve recognition of stroke symptoms and encourage immediate action. Awareness in Canada has roughly doubled over ten years, with nearly 60% of Canadians now able to recall at least two FAST signs, and 80% reporting that they would call 911 if they suspected a stroke. ²⁷ Adaptations of the campaign have also been developed for populations disproportionately impacted by inequities. A 3-year community engagement FAST campaign, initiated by the Northwestern Ontario Regional Stroke Network, was adapted for Indigenous children to raise awareness of stroke symptoms and the importance of prompt response. The centerpiece of the campaign was a creative educational product in the form of an 11.5-minute DVD titled Act F-A-S-T 1-2-3! featuring an indigenous elder in the role of a storyteller.²⁸

Emergency Medical Services (EMS) transport protocols and bypass agreements ensure that individual with stroke are rapidly transported to the most appropriate hospital with the capabilities to manage their specific needs. These protocols help EMS personnel identify potential cases of stroke in the field, assess stroke severity using standardized tools, and determine whether to bypass local hospitals in favor of a CSC or thrombectomy-capable hospital. Bypass agreements reduce treatment delays for individual with stroke eligible for procedures such as endovascular thrombectomy (EVT), by streamlining prehospital triage and transport. For example, the Acute Stroke Medical Redirect Paramedic Protocol (ASMRPP), legally empowers paramedics to bypass local hospitals and transport individuals with stroke directly to designated stroke centres when time and geography allow, significantly improved triage accuracy and treatment delivery. ²⁹ Direct transport by EMS to hospitals with on-site revascularization capability has been shown to improve treatment rates among eligible individual with stroke in other countries. ^30,31

Stroke rehabilitation is a vital component of a comprehensive stroke system of care, as it facilitates recovery, reduces long-term disability, and improves overall quality of life for individuals recovering from strokes. Rehabilitation begins in the acute phase, ideally within dedicated stroke units, where early mobilization and therapy assessments are associated with improved outcomes. ³² Following discharge, individual with stroke may transition to inpatient rehabilitation facilities, outpatient programs, or home-based services depending on their needs and functional status. Regardless of the setting, an extensive array of rehabilitation interventions has been shown to improve functional outcomes, psychosocial and participation outcomes, communication and cognition, and reduce medical complications. ^33,34 Within a stroke system of care, the inclusion of standardized rehabilitation pathways and assessments, coordinated discharge planning, and timely follow-up ensures continuity across care settings and supports patient-centered recovery goals. This continuum is particularly important in Canada, where geography and access disparities make organized, tiered systems of stroke care—including specialized rehabilitation units—essential for equitable service delivery.

Stroke secondary prevention services aim to reduce the risk of recurrent events. The risk of a stroke following TIA or stroke were estimated to be 5% and 9%, respectively within 90 days. ^35,36 Effective secondary prevention requires coordinated interdisciplinary care, emphasizing aggressive risk factor management (e.g., hypertension, atrial fibrillation, diabetes), and patient education. Patients who have experienced a minor stroke or TIA are unlikely to be admitted to hospital and will receive preventative care in stroke prevention clinics (SPC), during primary care visits with their family physician or through community-based programs. The use of rapid TIA clinics has been associated with a decreased risk of stroke recurrence. ^37,38 Across Canada, there are approximately 119 SPCs offering rapid outpatient assessment and management following a TIA or minor stroke. In Ontario there are 41 SPCs, and 29 across the three prairie provinces, serving as key access points within the provincial stroke system.³⁹ These clinics are located across all regions to ensure that nearly 87% of Canadians live within a one-hour drive of an SPC; however, only 69.2% have access to a service that operates 5-7 days a week. For individuals with stroke admitted to hospital, there are regional stroke centres with embedded SPCs, and inpatient and outpatient programs have been integrated into some inpatient rehabilitation settings, where individuals with stroke can receive tailored counseling on diet, exercise, smoking cessation, and medication adherence. In all of these settings, individuals with stroke may also receive services using virtual technologies. For example, Ontario Telemedicine Network (OTN) and BC Virtual Health support secondary prevention outreach in remote communities. Some SPCs also offer virtual consultations and follow-up.

As a component of a comprehensive stroke system of care, advance care planning (ACP) ensures that individual with stroke’ values, goals, and preferences guide medical decisions throughout the care continuum. Integrating ACP into stroke care allows healthcare providers to align treatments with patient wishes, avoid unwanted or non-beneficial interventions, and improve satisfaction among individual with stroke and families. In the broader stroke system, standardized processes for ACP promote consistency, support ethical decision-making, and help coordinate care across settings, from acute management to rehabilitation and long-term support. ACP interventions have been associated with higher levels of self-reported ACP engagement and increased ACP documentation in the electronic health record. ⁴⁰ Despite its importance, ACP engagement was reported to be low in a telephone survey of 50 patients who had experienced stroke or TIA, and 17 surrogates, in the United States. Engagement across individual 4 ACP behaviors ranged from 10% to 50%, including naming a surrogate decision-maker (46%), discussing wishes with a surrogate (50%), discussing wishes with a clinician (10%) and completing an advance directive (34%).⁴¹

Early integration of palliative care can reduce emotional distress, and facilitate informed decision-making, especially in cases where prognosis is uncertain or complex. Within a coordinated stroke system, access to palliative care ensures a patient-centered approach across all phases of care, including the transition to end-of-life support when needed. Lank et al. ⁴² reported that both informal and formal/ACP interventions were both associated with a shorter time to “comfort measures only’ status following stroke compared with no intervention.

Canada provides palliative care services through multiple settings. Care is delivered in home-based programs, in hospitals, where many institutions have designated palliative care units and consultation teams that address complex symptom management and end-of-life care, and in residential hospices and long-term care homes offer 24/7 specialized or shared palliative care in a supportive, home-like environment, often staffed by care providers and volunteers. Provincial organizations such as Hospice Palliative Care Ontario often coordinate these services, fostering integration between primary and specialist palliative care. Despite these programs, access varies widely across Canada, which averages fewer than four hospice beds per 100,000 people, well below recommended benchmark of 7 beds. ⁴³ People in rural and remote regions face the greatest service shortages. The 2019 Federal Action Plan seeks to address these gaps by improving data collection, expanding services (especially in underserved communities), and reinforcing culturally safe care. ⁴⁴ Five years later, progress continues to be made, but more work is needed. ⁴⁵

Sex & Gender Considerations

There are sex differences in stroke risk factors and outcomes. Traditional risk factors including atrial fibrillation, hypertension, diabetes, hyperlipidemia have been shown to confer a higher stroke risk in women, when present. ^46-48 Sex-specific risk factors such as pregnancy-related factors, oral contraceptive use, and hormone replacement therapy increases a women’s risk of stroke. The prevalence of stroke mimics is also higher in women. ⁴⁹ Women tend to be under-represented in stroke clinical trials. ⁵⁰ In terms of stroke outcomes, there is conflicting evidence as to whether there is a sex difference in case fatality, after adjusted for comorbidities, stroke severity and age, although more women die of stroke than men. ⁵¹ Women tend to experience worse functional outcomes, higher levels of disability, and lower quality of life after stroke compared with men.^52-54 As stroke systems of care are developed and the key components implemented, it will be important to take into account and integrate sex and gender as well as other equity-deserving groups.

1. Core Elements of Stroke Systems of Care

Recommendations and/or Clinical Considerations

1.0 Structure of Stroke Systems of Care

1.1 Core Elements of a Stroke System

Stroke Resources