“Are we there yet?” The repetitive question asked by impatient children that adds tension to every long family road trip can also be applied to the goal of equitable stroke care in Canada. Nationalized health systems devote significant efforts to produce equitable access to care. Ontario, Canada, has one of the most developed stroke systems in the country. The manuscript by Taghdiri et al. (2025) should provoke thought and reflection on how successful we are in attaining equity. ^{Reference Taghdiri, Vyas and Kapral1}

This retrospective cohort study uses administrative databases from Ontario examining adults hospitalized with ischemic stroke from 2017 to 2022. It investigates the impact of driving distance to the nearest comprehensive stroke center (CSC) and rurality on the use of medical thrombolysis and endovascular thrombectomy (EVT). Driving distance was measured from the patient’s residence, and the methodology is quite sound to address the research question.

The investigators found that increasing driving distance reduced the odds of receiving EVT. Patients living more than 120 km from a CSC experienced a 20% reduction in the odds of receiving EVT, and those living >240 km had a 60% reduction. Although it might seem intuitive that greater distance would be associated with reduced access for a time-sensitive condition, one has to consider that the EVT window can extend to even 24 hours for selected patients. While delays might be expected for those living farther away, to lose access entirely to the degree reported based on distance is concerning.

The authors found no relationship between access to thrombolysis and driving time to CSC, concluding equitable access across Ontario based on geography. ^{Reference Taghdiri, Vyas and Kapral1} However, an analysis of driving time to a thrombolysis center – which includes CSCs plus primary stroke centers – would be required to exclude any association. This is particularly true since a reduction in thrombolysis access from driving time has been previously demonstrated in other jurisdictions. ^{Reference Ader, Wu and Fonarow2}

Although only 7%–8% of patients lived more than 120 km from a CSC, this could represent over 1.2 million people with suboptimal access across Ontario if the general population has a similar geographic distribution (Supplemental Figure 2). ^{Reference Taghdiri, Vyas and Kapral1} Figure 3 highlights that over 50% of Ontario would fall in the 121–400 minute driving zone. The problem is magnified when considering provinces and territories that do not have stroke systems as developed as Ontario’s. Even in many provinces with developed stroke systems, the CSCs are clustered in southern regions, leaving northern communities underserved. ^{Reference Eswaradass, Swartz, Rosen, Hill and Lindsay3}

Clearly, access is improving in Canada compared to several years ago with the availability of more CSCs and the expansion of the EVT window. ^{Reference Eswaradass, Swartz, Rosen, Hill and Lindsay3} The study results also suggest that previous findings in the literature of poorer access to EVT based on rural residence may be explained mostly by the distance of communities from a CSC. ^{Reference Taghdiri, Vyas and Kapral1,Reference Yan, Hu and Alcock4,Reference Dwyer, Rehman and Ottavi5}

The authors provide a number of suggestions to address the issue of access. Aside from optimizing air transport systems, implementing efficient rendezvous strategies between ground and air units is essential. In addition, smaller centers such as Thunder Bay in Ontario and Kelowna in BC, which have developed into CSCs, should be supported. Empowering small urban centers to be EVT capable could significantly improve access nationwide, although challenges like recruitment, specialized staffing, and maintaining skill volume must be addressed. Provinces should collaborate to address these challenges.

Stroke practitioners, administrators, and policymakers also need to ask the question “are we there yet?” again and again, impatiently, about equitable access to acute stroke care. Currently, the answer is the same one that parents frequently give about the destination of the long drive. “We aren’t there yet – but we are getting closer.”