System-level gaps in stroke referral pathways in Georgia: implications for policy and practice

Background

Every minute of delay in stroke care leads to irreversible brain damage, making timely referral to specialized centers critical for survival and disability outcomes. Despite European standards emphasizing organized stroke systems, limited data infrastructure and variability in clinical decision-making in Georgia may hinder adherence. This study explores institutional and provider-level challenges in stroke referral pathways.

Methods

A nationwide cross-sectional survey was conducted among heads of medical institutions (n = 325) and healthcare professionals, including state emergency physicians (n = 100), private emergency physicians (n = 25) and family physicians (n = 125). A structured, guideline-informed questionnaire assessed referral practices, awareness of stroke management centers and system-level barriers. Data were analyzed descriptively.

Results

Institutional respondents were unable to provide key stroke indicators, including patient volumes, delays and referral patterns, reflecting the absence of organized data systems. Only 20.1% considered referral to stroke management centers necessary, while 66.7% preferred referral to the nearest clinic with a neurology department and 13.2% to facilities with only an emergency department. At provider level, 16% reported no awareness of stroke centers and 23.7% did not consider referral mandatory. Referral decisions were mainly driven by geographical accessibility and availability of neurology services (39.4%), rather than guideline-based criteria.

Conclusions

Stroke referral pathways in Georgia are shaped by system constraints rather than evidence-based standards. Weak data systems and limited awareness of specialized services contribute to suboptimal decision-making and delayed access to time-sensitive care. Strengthening data infrastructure and standardized referral protocols should be prioritized to improve outcomes.

Key messages

• Stroke referral in Georgia is largely driven by accessibility rather than evidence-based pathways, potentially delaying optimal care.

• Timely policy action is needed to strengthen data systems and implement standardized stroke referral pathways to improve access to care.