Each year, an estimated 795,000 persons in the United States experience a stroke. In all, an estimated 7 million U.S. residents have had a stroke, and the cost of cerebrovascular disease in 2007 was estimated at $41 billion. During 2004--2009, CDC funded seven state health departments for different periods to implement stroke care improvement registries. As part of the quality-improvement activities conducted by the Paul Coverdell National Acute Stroke Registry (PCNASR), CDC monitors adherence to 10 quality-of-care measures. This report documents the status of adherence to these 10 performance measures of stroke care through these seven state health departments for the period 2005--2009. The number of participating hospitals in the seven states ranged from 112 to 229 per year, with a total of 303 participating hospitals during the 5-year period. Average annual improvement in adherence to stroke care measures ranged from zero in one measure (prescription of antithrombotic at discharge) to 11% (use of intravenous tissue plasminogen activator [IV tPA]); five measures showed average annual improvements of at least 6%. The proportion of patients receiving "defect-free care" (a descriptor that indicates whether patients received all of the quality-of-care measures for which they were eligible) also improved. These results demonstrate the ability of state health departments to collaborate with hospitals to monitor and improve the delivery of high-quality care for acute stroke patients. This role for public health and state health departments in hospital quality improvement for acute stroke care is a viable approach to improving the quality of stroke care in the United States.