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Introduction: Hospital arrival by emergency medical services (EMS) is important for decreasing time from stroke onset to arrival and increasing the rate of rtPA use. In rural states, like Iowa, EMS is an often volunteer and dispersed resource which may influence the use of private vehicles.Objective: The objective of this study was to identify predictors of EMS use compared to private vehicle transport in Iowa stroke patients.Methods: A retrospective analysis was conducted using 2016 data collected by the Iowa Stroke Registry. The Iowa Stroke Registry is a statewide, concurrent database used to improve the Iowa Stroke System and quality of stroke care between EMS and hospitals in Iowa (1 comprehensive center, 15 primary centers, and 9 acute stroke hospitals). Inclusion was limited to arrival by EMS or private vehicles in the year 2016; all other arrivals were excluded. Predictors of EMS use were evaluated from admission, arrival, demographic, medical history, and hospital data. Chi square analyses and multivariate logistic regression were performed to determine associations and predictors of EMS use. Significance was at the 0.05 probability level.Results: The inclusion criteria was met by 2650 patients with 1335 (50.4%) arriving by EMS. A total of 1739 patient records were included in the analysis and 829 (47.7%) arrivals were from EMS compared to private vehicles. Results from the multivariate analysis indicated that EMS use was significantly associated with patients aged 65 or older, Native Americans, neurological symptoms of altered consciousness, aphasia, and weakness, history of atrial fibrillation, antidepressant medication use, hormone replacement therapy, and arrival in the northeast, south central, and southeast regions of the state. Private vehicle use was associated with resolved stroke symptoms at initial exam and the ability to ambulate independently prior to stroke. Patients arriving by EMS were more likely to arrive in the first 2 hours of symptom onset and receive rtPA compared to private vehicle arrivals.Conclusion: The proportion of arrivals by EMS and private vehicles were similar in 2016. Neurological symptoms of stroke, age, ambulatory status and region of the state were the most influential factors in determining EMS use.