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Background: Guideline-concordant processes of care improve longitudinal outcomes in patients with acute stroke. Little is known whether there are different processes of acute ischemic stroke (AIS) care or outcomes between secondary and tertiary hospitals.Methods: We analyzed 19 604 AIS patients across 219 hospitals in China National Stroke Registry II from June 2012 to January 2013. The primary outcome was guideline-concordant care, defined as compliance with 13 guideline-recommended performance metrics and composite score. Propensity score matching was used to balance the baseline characteristics. We used cox model and logistic regression with generalized estimating equation to compare the relationship between secondary and tertiary hospitals on quality measures and all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge.Results: Among 19 604 AIS patients, 6 038 (30.8%) and 13 566 (69.2%) were admitted to 66 (30.1%) secondary and 153 (69.9%) tertiary hospitals separately. After matching, 5959 pairs of patients in secondary and tertiary were analyzed. The composite score was higher at tertiary hospitals than secondary hospitals (77% versus 74%, P<0.001). Tertiary hospitals were more likely to perform early antithrombotic, carotid imaging, anticoagulation for atrial fibrillation, antihypertensive therapy, hypoglycemic medications, and rehabilitation (Figure 1). Furthermore, comparing to AIS patients among tertiary hospitals, those admitted to secondary hospitals had higher hazard of disability at 3 months (19.3% versus 21.5%) and 1-year stroke recurrence (4.4% versus 5.4%) after matching.Conclusions: In China, tertiary hospitals have better processes of AIS care and more favorable clinical outcomes than secondary hospitals. The quality of process of AIS care should be further increased to improve the patients’ clinical outcomes especially among secondary hospitals.