Does where we live influence the care received in a nationalized health system? This question draws attention to the relationship between residential location and access to comprehensive acute and post-stroke healthcare services. The article by Buchel et al. provides an insightful evaluation of the differences in healthcare utilization among ischemic stroke patients in rural versus urban Manitoba. ^{Reference Buchel, Siddiqi and Ghrooda1}

In this observational study, the authors used the Discharge Abstract Database, which includes ischemic stroke patients who received care in any hospital within Manitoba from 2019 to 2023, to assess regional differences and stroke trends over time, reporting notable geographical disparities in stroke care and outcomes. The investigators categorized ischemic stroke patients by whether they received care within the Winnipeg health region (metropolitan) or outside of it (non-metropolitan).

Only 3.7% of non-metro patients received thrombolysis compared to 16.7% for Winnipeg, which is a striking discrepancy despite the creation of a provincial Telestroke system. However, the Manitoba Telestroke system was still forming at the beginning of the surveillance period. Also, up to 12.4% of Manitobans do not live within 4.5 hours driving time of the eight thrombolysis centers in the province. Almost all patients with poor access will be from non-metro areas. Despite higher stroke incidence in Winnipeg, hospital mortality was not significantly different between the two regions, consistent with other Canadian data. ^{Reference Fleet, Bussières and Tounkara2,Reference Kapral, Austin and Jeyakumar3} The absence of data on the provision of endovascular thrombectomy is a limitation of the study that hopefully will be addressed by future research. The study highlights the challenges Canadian provinces face in delivering equitable care despite expending significant effort. Manitoba can be commended for implementing a provincial stroke strategy and creating a telestroke network despite the substantial administrative, political and financial barriers to doing so. Now the province needs to focus on quality improvement within that network. With the existence of seven non-metro telestroke centers, the focus should be on increasing the proportion of all non-metro ischemic stroke patients who receive thrombolysis. Other Canadian jurisdictions that do not yet have organized stroke systems should understand that such systems are long overdue and that rural patients likely have the most to benefit. Those that have such systems should be monitoring their data and ensuring that access to acute stroke care is increasing over time in all regions. Only a very organized approach, with health authority commitment and resources, will ensure that in the future, access to the best stroke care will be less dependent on where you live than it is now.