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Globally, national stroke registries have been shown to improve the quality of patient care and outcomes. However, registry utilization and implementation vary by country. In the United States, stroke-specific performance measures must be met to achieve and maintain stroke center certification awarded by the state or nationally accredited certifying bodies. The 2 stroke registries available in the United States are the American Heart Association Get With The Guidelines-Stroke registry, which is voluntary, and the Paul Coverdell National Acute Stroke Registry, funded competitively to states by the Centers for Disease Control and Prevention. Compliance with stroke processes of care is variable, and quality improvement initiatives among organizations have been shown to have an impact on improving stroke care delivery. However, the effectiveness of interorganizational continuous quality improvement approaches, especially among competing institutions, to improving stroke care is ambiguous, and no uniform governance for successful interhospital collaboration has been identified. The purpose of this article is to review national initiatives focused on interorganizational collaboration to improve stroke care delivery with a focus on interhospital collaboration in the United States to improve stroke performance measures specific to stroke center certification. The state of Kentucky’s experience and utilization of the Institute for Healthcare Improvement Breakthrough Series model with key strategies for success will be discussed to serve as a foundation and empower novice stroke leaders in learning health systems. The models may be adapted internationally for application to stroke-specific care process improvement locally, regionally, and nationally; among organizations within the same health system or competing systems; and among organizations with funding or without funding to improve stroke performance measures.

IntroductionThe burden of Alzheimer’s disease (AD) and AD-related dementias (ADRD) is increasing nationally and globally, with disproportionate impacts on lower-income, lower education and systematically marginalised older adults. Presence of inequalities in neighbourhood factors (eg, social context, physical and built environments) may affect risk of cognitive decline and be key for intervening on AD/ADRD disparities at the population level. However, existing studies are limited by a dearth of longitudinal, detailed neighbourhood measures linked to rich, prospective cohort data. Our main objective is to identify patterns of neighbourhood change related to prevalence of—and disparities in—cognitive decline and dementia.Methods and analysesWe describe the process of collecting, processing and linking extensive neighbourhood data to the Multi-Ethnic Study of Atherosclerosis (MESA), creating a 25+ years dataset. Within the MESA parent study, the MESA Neighborhoods and Aging cohort study will characterise dynamic, longitudinal neighbourhood social and built environment variables relevant to cognition for residential addresses of MESA participants. This includes administering new surveys, expanding residential address histories, calculating new measures derived from spatial data and implementing novel deep learning algorithms on street-level imagery. Applying novel statistical techniques, we will examine associations of neighbourhood environmental characteristics with cognition and clinically relevant AD/ADRD outcomes. We will investigate determinants of disparities in outcomes by socioeconomic position and race/ethnicity and assess the contribution of neighbourhood environments to these disparities. This project will provide new evidence about pathways between neighbourhood environments and cognitive outcomes, with implications for policies to support healthy ageing.Ethics and disseminationThis project was approved by the University of Washington and Drexel University Institutional Review Boards (protocols #00009029 and #00014523, and #180900605). Data will be distributed through the MESA Coordinating Center. Findings will be disseminated in peer-reviewed scientific journals, briefs, presentations and on the participant website.

Background Transport walking has drawn growing interest due to its potential to increase levels of physical activities and reduce reliance on vehicles. While existing studies have compared built environment-health associations between Euclidean buffers and network buffers, no studies have systematically quantified the extent of bias in health effect estimates when exposures are measured in different buffers. Further, prior studies have done the comparisons focusing on only one or two geographic regions, limiting generalizability and restricting ability to test whether direction or magnitude of bias are different by context. This study aimed to quantify the degree of bias in associations between built environment exposures and transport walking when exposures were operationalized using Euclidean buffers rather than network buffers in diverse contexts. Methods We performed a simulations study to systematically evaluate the degree of bias in associations between built environment exposures in Euclidean buffers and network buffers and transport walking, assuming network buffers more accurately captured true exposures. Additionally, we used empirical data from a multi-ethnic, multi-site cohort to compare associations between built environment amenities and walking for transport where built environment exposures were derived using Euclidean buffers versus network buffers. Results Simulation results found that the bias induced by using Euclidean buffer models was consistently negative across the six study sites (ranging from -80% to -20%), suggesting built environment exposures measured using Euclidean buffers underestimate health effects on transport walking. Percent bias was uniformly smaller for the larger 5 km scale than the 1 km and 0.25 km spatial scales, independent of site or built environment categories. Empirical findings aligned with the simulation results: built environment-health associations were stronger for built environment exposures operationalized using network buffers than using Euclidean buffers. Conclusion This study is the first to quantify the extent of bias in the magnitude of the associations between built environment exposures and transport walking when the former are measured in Euclidean buffers vs. network buffers, informing future research to carefully conceptualize appropriate distance-based buffer metrics in order to better approximate real geographic contexts. It also helps contextualize existing research in the field that used Euclidean buffers when that were the only option. Further, this study provides an example of the uncertain geographic context problem.

We employed a longitudinal distributed lag modeling approach to systematically estimate how associations between built environment features and transport walking decayed with the increase of distance from home to built environment destinations. Data came from a cohort recruited from six U.S. cities (follow-up 2000-2010, N = 3913, baseline mean age 60). Built environment features included all walkable destinations, consisting of common and popular destinations for daily life. We also included two subsets frequent social destinations and food stores to examine if the spatial scale effects differed by varying density for different types of built environment destinations. Adjusted results found that increases in transport walking diminished when built environment destinations were farther, although distance thresholds varied across different types of built environment destinations. Higher availability of walking destinations within 2-km and frequent social destinations within 1.6-km were associated with transport walking. Food stores were not associated with transport walking. This new information will help policymakers and urban designers understand at what distances each type of built environment destinations influences transport walking, in turn informing the development of interventions and/or the placement of amenities within neighborhoods to promote transport walking. The findings that spatial scales depend on specific built environment features also highlight the need for methods that can more flexibly estimate associations between outcomes and different built environment features across varying contexts, in order to improve our understanding of the spatial mechanisms involved in said associations.

Although dense neighborhood built environments support increased physical activity and lower obesity, these features may also disturb sleep. Therefore, we sought to understand the association between the built environment and objectively measured sleep. From 2010 to 2013, we analyzed data from examination 5 of the Multi-Ethnic Study of Atherosclerosis, a diverse population from 6 US cities. We fit multilevel models that assessed the association between the built environment (Street Smart Walk Score, social engagement destinations, street intersections, and population density) and sleep duration or efficiency from 1-week wrist actigraphy in 1,889 individuals. After adjustment for covariates, a 1-standard-deviation increase in Street Smart Walk Score was associated with 23% higher odds of short sleep duration (≤6 hours; odds ratio = 1.2, 95% confidence interval: 1.0, 1.4), as well as shorter average sleep duration (mean difference = −8.1 minutes, 95% confidence interval: −12.1, −4.2). Results were consistent across other built environment measures. Associations were attenuated after adjustment for survey-based measure of neighborhood noise. Dense neighborhood development may have multiple health consequence. In promoting denser neighborhoods to increase walkability, it is important to also implement strategies that reduce the adverse impacts of this development on sleep, such as noise reductions efforts.

Background: The WHO estimates that only 50% of patients with chronic illness adhere to treatment recommendations. The Affordable Care Act targets hospital readmission rates as cost savings opportunities. Readmission rates reported in the literature range from 6-33%. Transitional care programs have been shown to improve patient outcomes. Purpose: To reduce readmission and recurrent stroke, the Stroke Patient Education and Navigation (SPEN) Project sought to enhance the continuum of care post discharge by forming collaboration between the University of Louisville Stroke Center (UL), Taylor Regional Hospital (TRH) and the Department for Public Health. Primary outcomes of this three-year project were hospital readmission, medication adherence, utilization of community resources, and National Quality Forum (NQF) 18: blood pressure less than 140/90. Methods: Stroke patients transferred from TRH to UL discharged home from October 2013 to January 2015 were invited to participate. After discharge nurses made 3 home visits at 2 weeks, 3 months, and 6 months to assess outcomes, biometrics, and blood pressure self-management. A follow up phone call was made at one year. Results: 44 patients participated (mean age 70, 28 male, 16 female). 32/44 (73%) completed all 3 visits. 36/44 (82%) with medication adherence. 2/44 (5%) readmitted within 30 days (1 with TIA and 1 with pneumonia). 2/24 (8%) participated in a community resource (smoking cessation program and diabetes classes). Reasons for not using community resources were lack of transportation and “not needed”. Results of NQF 18 goals achieved: 29/44 (66%) at visit 1 and 12/28 (43%) for all 3 visits. At one-year post discharge 10 patients had been readmitted, 3 for vascular events (1 TIA, 1 MI, 1 HTN). Cost of project per patient was $306.62. Conclusions: the SPEN project achieved low 30-day readmission rate and positive medication compliance, but did not achieve utilization of community resources or satisfactory NQF 18 results. Future projects should consider methods to improve resource utilization and cost effective methods of follow-up, such as multiple telephone or telehealth interactions.

Background and Issues: Research has shown that dysphagia occurs within 3 days of a stroke in 42-67% of patients. Of those, 50% aspirate, leading to higher morbidity and mortality due to complications such as pneumonia, dehydration and malnutrition. After reviewing aggregate Get With The Guidelines data, a voluntary group of Kentucky hospitals named SEQIP (Stroke Encounter Quality Improvement Project) was convened and agreed to share data. SEQIP, which included certified stroke centers and those pursuing certification working in collaboration with the AHA/ASA and the KY Department of Public Health, implemented a statewide QI Plan in an effort to improve the care of stroke patients with regard to bedside dysphagia screening prior to oral intake. Purpose: The purpose of this hospital collaboration was to increase overall compliance of bedside dysphagia screening for acute stroke patients by implementing a unified statewide effort. Methods: Baseline bedside dysphagia screening results were reviewed from 16 SEQIP hospitals. Using an interdisciplinary continuous quality improvement process, SEQIP hospitals shared best practices and dysphagia screening tools, such as Just Add Water, NPO Until You Know, Toronto Bedside Swallowing Screening Test, and other validated screening tools. SEQIP then developed a statewide QI Plan that supported integration of evidence-based bedside dysphagia screening, monitoring, evaluation, reporting and accountability at each member hospital. Results: SEQIP’s participating hospitals achieved improvement in screening rates compared to 2008 baseline data as a direct result of quality improvement techniques. Between 2008 and 2014, SEQIP achieved a 28.9% increase in proportion of eligible patients (n=27616) receiving screening (from 62.87% to 91.81%). SEQIP hospitals demonstrated year-by-year improvement in performance. In the analysis, statistically significant (p Conclusions: Collaboration between hospitals, sharing of best practices, identification of evidence-based dysphagia screening tools, and the development of a unified QI Plan resulted in improved statewide compliance with bedside dysphagia screening before oral intake.

The objectives of this study were to assess the feasibility of using urinary recovery of sugars to evaluate intestinal permeability and absorption in dogs with traumatic injury and to determine if intestinal permeability and absorption are altered in dogs with traumatic injury. After a 6-hour fast, a sugar solution containing lactulose, rhamnose, 3-O-methyl-D-glucose, and xylose was administered via nasoesophageal tube. Urine was collected and quantitated over the 6-hour study period via closed collection urinary catheters. Urinary sugar recoveries were measured by high-pressure anion exchange liquid chromatography and pulsed amperometric detection. Urinary sugar recoveries in the trauma group at 24, 48, and 72 hours after trauma were compared to normal controls. In addition, severity of trauma was compared to urinary sugar recoveries. Twelve client-owned dogs with traumatic injury and 6 healthy controls were enrolled in the study. Lactulose recovery and the lactulose: rhamnose recovery ratio were significantly higher in the trauma group at 48 hours but were no longer different from controls by 72 hours. Xylose recovery was significantly higher in the trauma group when compared to controls at 72 hours, whereas 3-O-methyl-D-glucose recovery was significantly lower in the trauma group at 24 hours. The xylose: 3-O-methyl-D-glucose ratio was higher in the trauma group at all time points. Significant correlation was found between severity of trauma and xylose and 3-O-methyl-D-glucose recoveries 24 hours after injury. Results of this study support the hypothesis that intestinal permeability and absorption are altered in dogs with traumatic injury.