The last and only real question in this debate is whether stroke center designation improves patient outcomes. The recently published New York study in JAMA that Dr. Alberts cited showed lower mortality in designated stroke centers than in non–stroke center hospitals, but there are differences between those groups: Stroke centers tended to treat younger patients and those in urban areas, with more teaching hospitals and larger hospitals. The investigators tried to control for those factors, but one thing they could not control for was the fact that hospitals chose to become primary stroke centers. They had the capabilities, and it was feasible at those centers to become primary stroke centers. Already, they were at an advantage.

There is just no solid evidence that the designation improves outcomes for patients. Care differs among hospitals prior to certification. Care improves when you watch it, and was improving well before the certification process began.

Some elements of stroke centers are associated with better care, but certification as a stroke center is not required to pursue those elements. Hospitals that elect to become certified are more likely to provide better stroke care before certification, and are already committed to improving care.

I want to pose a different question: Does society benefit from stroke center certifications? I think the answer is “Yes.” The system of certifying stroke centers provides a framework for regionalization. With stroke center certification, we can convince our EMS teams that they need to bypass the noncertified hospitals and bring stroke patients to hospitals that provide better stroke care. Getting patients to hospitals that provide better care definitely will improve overall care on a societywide level.

Dr. Johnston is professor of neurology and epidemiology and director of the stroke service at the University of California, San Francisco. He said he has no relevant conflicts of interest.