OBJECTIVE: To evaluate whether 1) a dedicated, multispecialty service, 2) a distinct hospital ward, 3) protocols, and 4) a specialist are associated with reduced mortality among patients with stroke. METHODS: The authors reviewed data (1998 and 1999) from all acute, non-federal hospitals in California, including administrative discharge databases for patient and hospital-level information, mortality data through 1 year post discharge, and a hospital-level survey regarding structural elements of stroke care. The impact of a dedicated, multidisciplinary stroke service and of stroke wards, protocols, and specialists on odds of death among patients with ischemic and hemorrhagic stroke were each examined using logistic regression models. How these elements of care impacted outcome at teaching vs non-teaching hospitals was also examined. RESULTS: A 67.5%response rate (257/381) from surveyed hospitals provided data for 61,541 patients with stroke. A dedicated, multispecialty stroke service was available at 7.4%of hospitals. Twelve percent of hospitals had a stroke ward, 62.3%used protocols, and 16%had neurologists with specialty training in stroke. Patients cared for at hospitals with a dedicated stroke service had significantly lower odds for death at 30 days, and reduced mortality was maintained through 365 days after admission. Stroke wards, protocols, and specialists were not associated with reduced mortality. Having a dedicated stroke service was associated with reduced mortality at both non-teaching and teaching hospitals. CONCLUSIONS: Dedicated, multispecialty stroke services are underutilized despite their association with reduced stroke mortality at both academic and non-academic hospitals. METHODS: The authors reviewed data (1998 and 1999). OBJECTIVE: To evaluate whether 1) a dedicated, multispecialty service, 2) a distinct hospital ward, 3) protocols, and 4) a specialist are associated with reduced mortality among patients with stroke. from all acute, non-federal hospitals in California, including administrative discharge databases for patient and hospital-level information, mortality data through 1 year post discharge, and a hospital-level survey regarding structural elements of stroke care. The impact of a dedicated, multidisciplinary stroke service and of stroke wards, protocols, and specialists on odds of death among patients with ischemic and hemorrhagic stroke were each examined using logistic regression models. RESULTS How these elements of care impacted outcome at teaching vs non-teaching hospitals was also examined. A 67.5% response rate (257/381) from surveyed hospitals provided data for 61,541 patients with stroke. A dedicated, multispecialty stroke service wa Twelve percent of hospitals had a stroke ward, 62.3% used protocols, and 16% had neurologists with specialty training in stroke. Patients cared for at hospitals with a dedicated stroke service had significantly lower odds for death at Having a dedicated stroke service was associated with reduced mortality at both non-teaching and teaching hospitals. CONCLUSIONS: Dedicated , multispecialty stroke services are underutilized despite their association with reduced stroke mortality at both academic and non-academic hospitals.