In 2001, Congress provided funding to the Centers for Disease Control and Prevention (CDC) for the Paul Coverdell National Acute Stroke Registry (PCNASR) to implement state-based stroke registries. These registries track and measure QoC for stroke patients from prehospital emergency medical services (EMS) through acute care, secondary prevention, and rehabilitation, and they promote changes in hospital policies and systems to improve delivery of care (3). After prototype testing, CDC funded four state health departments for 3 years to establish the PCNASR in their states. State public health departments implement the PCNASR and foster QI by collaborating with physicians, hospital management, hospital QI teams, and others striving to improve stroke care. Similar to the PCNASR QI initiatives, efforts are under way to improve the QoC and response times of EMS for people with acute symptoms of stroke and heart disease. Integration of QI within state health departments for stroke care will increase opportunities to develop statewide systems of stroke care. Integration of stroke-related activities of EMS, hospitals, clinicians, and other providers of stroke care should improve access to care and ultimately refine policies and stroke systems of care.

State health departments continuously evaluate their QI interventions (e.g., dysphagia screening to prevent aspiration pneumonia and initiation of secondary prevention) that improve care for stroke patients. Results from the prototype registries identified gaps in acute care for stroke, underscoring the importance of continuously monitoring QoC indicators and the need for QI interventions (4).

During the past decade, federal agencies collaborated with the American College of Surgeons and other partners to oversee development of trauma care registries to improve QoC for both individual trauma patients and systems of trauma care. This effort is an essential component of effective statewide trauma care. Because trauma is an important public health problem (5,6), the National Trauma–EMS Stakeholder Group, directed by the Health Resources and Services Administration (7), recently adopted a public health approach for developing trauma systems, allowing for the inclusion of trauma care professionals, public health officials, and health care policy experts. State health departments have contributed to assessment of both patient-level QoC and the trauma system itself through the three core functions of public health.

The Institute of Medicine (IOM) recommended that state health departments' public health duties (1) include "assessment of health needs within the state based on statewide data collection," "assurance of an adequate statutory base for health activities in the state," and "assurance of appropriate organized statewide effort to develop and maintain requisite personal, educational, and environmental health services." QI in stroke care is a multidisciplinary, systems-focused effort engaging public and private entities and involving a wide spectrum of care. Because state health departments have considerable influence over their states' health care budget, policies, and regulations, they are key in providing leadership in QI through policy development and assurance. The IOM-stated public health duties have practical implications for QI in health care. The IOM recommendations and QI experience in public health (8) illustrate the leadership role of state health departments in ensuring QI of stroke care.

One of the most effective ways to improve care for stroke is to engage and continually collaborate with critical stakeholders (9) (Table). State health departments can evaluate new advances in stroke care and assess pertinent issues in systems of stroke care. Such prevention efforts should include primordial prevention (reduction of risk factors), primary prevention (identification and treatment of risk factors), and secondary prevention (prevention of recurrent stroke) (10).

The ultimate goal of engaging stakeholders in stroke care is to implement effective policies, practices, and programs that prevent stroke, control risk factors, and improve the QoC and outcomes of stroke patients. State health departments should further this goal by implementing stroke programs that increase awareness of symptoms and risk factors for stroke while measuring disease burden within the state.

The American Stroke Association's Task Force on the Development of Stroke Systems has developed recommendations for establishing systems of stroke care (10), and public health agencies at all levels support many of these recommendations. Three examples of these key components of stroke systems of care and the ways in which public health helps to develop them follow.

PCNASR provides a model for other public health efforts to improve the QoC for cardiovascular diseases, such as acute coronary syndrome and heart failure. In 2004, the American Heart Association updated its guidelines for managing ST-elevation myocardial infarction (STEMI) (13) and, more recently, updated recommendations for developing systems of care for acute coronary syndrome, which include a role for public health (14).

In 2004, the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry examined use of performance measures for improving QoC for patients with heart failure. Adherence to performance measures did not correlate well with death or rehospitalization performance measures for heart failure in 259 U.S. hospitals (15,16), indicating a need for better methods or different performance measures to assess and improve care of patients with heart failure (16). Nevertheless, the increasing numbers of patients with heart disease, the chronic nature of their disease, the associated high costs, and frequent hospitalizations reinforce the need to evaluate and promote QoC in this area.

The PCNASR aims to integrate the stroke-related activities of EMS, hospitals, and providers of stroke care to promote stroke systems of care and to enhance QoC for stroke patients. Integration of these services and providers could extend to QoC for acute coronary syndrome and heart failure patients in developing QI-focused systems of care for these diseases as well. State public health departments can coordinate efforts to improve QoC for these cardiovascular diseases.