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The majority of the 800,000 strokes occurring in the US each year are first-time strokes. To understand how these can be prevented, our study assessed primary care (PC) treatment of common stroke risk factors (RF) in the year prior to a first-time stroke. We compared hospitals in three major health systems – a California County (OVMC), VA (WLAVA), and Kaiser HMO (KSD), both before and after the Affordable Health Care Act (ACA).Methods: We identified patients who suffered a first-time stroke in 2013 and 2015 at all three sites. We then assessed the three most recent PC visits for these patients in the year before their stroke for “missed opportunities” (MO) in stroke preventative care. MOs included: Systolic blood pressure (SBP) >140 not addressed, elevated A1C not addressed, LDL never checked or >100 but not addressed, antiplatelet medication not refilled, and no RF counseling (smoking, alcohol, obesity, or physical activity). MOs were compared between sites, before (2013) and after the ACA (2015).Results: 85 patients from OMVC, 88 patients from KSD and 64 patients from WLAVA met entry criteria. All sites had an increase in the number of patients who had PC visits prior to first-time stroke between 2013 and 2015 (OVMC 2013: 1/26, 2015 15/59 (25.4%). KSD 2013: 50/67 (74.6%), 2015 16/21 (76.2%). VA 2013: 24/33 (72.7%) 2015 28/31 (90.3%). In 2013, only one OVMC patient had primary care. In 2013, the WLAVA had significantly less MO than Kaiser (23.6% vs 59.0%, p<0.001). In 2015, there was no significant difference in MO between the three sites (p=0.21). The most common MOs were in addressing hypertension, elevated LDL, and lack of RF counseling.Conclusions: Stroke RFs were often not addressed during PC visits at all 3 sites. All sites had an increase in PC visits among first-time stroke patients after the ACA, particularly within the LA County system. It is unclear if this resulted in increased stroke RF counseling and intervention. Efforts to promote primary stroke prevention are still needed.