Place Matters: Closing the Gap on Rural Primary Care Quality Improvement Capacity—the Healthy Hearts Northwest Study

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Figure 1.
Mean Quality Improvement Capacity Assessment (QICA) self-assessment subscores and totals for 135 primary care practices in Healthy Hearts Northwest, by ownership type and rural/urban location. A. Rural practices had the lowest scores at baseline. B. Almost all gains over the course of the year were statistically significant with 95% confidence intervals (CIs) that did not include zero (vertical dashed line). The group mean changes were not statistically different from each other (CIs overlap).

Table 1.

Practice Characteristics^*

Characteristics	Rural				Urban				P value
	Independent (N = 20)		Health System (N = 34)		Independent (N = 55)		Health System (N = 26)
	n	%	n	%	n	%	n	%
Practice size
1 (solo)	3	15	1	3	18	33	2	8	.01
2 to 4	12	60	19	56	20	36	14	54
5 or more	5	25	14	41	17	31	10	38
Specialty: Family Medicine	16	80	24	71	41	75	19	73	.9
Clinicians-assigned panels	16	80	31	91	41	75	25	96	.047
Panel size (in practices with panels), median (quartiles)	1175 (494 to 2000)		1000 (600 to 1171)		1550 (675 to 2478)		1000 (676 to 1466)		.053
% Medicaid	22	19	24	12	19	26	28	20	.011
% Medicare	30	19	30	15	21	17	26	19	.049
No central QI support	15	75	8	24	43	80	5	19	<.001
Complete/a lot of autonomy to choose QI projects	16	80	23	68	49	91	15	58	.005
Number of major disruptions during study period
2 or more	15	75	24	71	24	44	12	46	.028
1	1	5	5	15	13	24	6	23
0	4	20	5	15	18	33	8	31
Ever run nonstandard CQM report	4	20	19	56	15	29	10	40	.069
Confident (4 or 5 out of 5) generating CQM report	7	35	10	30	27	53	7	30	.12
Baseline QICA,mean (SD)	6.0 (1.8)		6.2 (1.0)		6.6 (1.5)		6.7 (1.4)		.21
Number of in-person visits by practice facilitation staff, mean (SD)	8.0 (2.9)		8.6 (2.1)		9.0 (3.0)		8.7 (3.2)		.57

CQM, clinical quality measure; QI, quality improvement; QICA, quality improvement capacity assessment; SD, standard deviation.
↵* Results are represented as number and percentage unless noted otherwise.

Table 2.

Clinical Quality Measures Performance from 2015 to 2017 (n = 135)

CQM		Baseline Mean (SD)	Final Mean (SD)	Change
CQM		Baseline Mean (SD)	Final Mean (SD)	Mean	95% CI	P value
Blood pressure	R-I^*	55.5 (11.6)	66.1 (10.2)	10.6	6.2, 15.0	<.001
	R-HS	61.2 (10.0)	63.5 (10.1)	2.3	−1.9, 6.6	.29
	U-I^‡	65.8 (13.0)	64.7 (11.3)	−0.7	−4.3, 2.9	.71
	U-HS^‖	62.4 (11.0)	68.5 (12.3)	6.1	3.6, 8.7	<.001
Aspirin	R-I	57.4 (20.6)	67.8 (14.1)	10.3	−1.0, 21.6	.08
	R-HS	69.6 (9.1)	72.5 (10.7)	2.9	−1.7, 7.4	.22
	U-I	63.7 (17.9)	69.6 (13.9)	6.0	1.2, 10.9	.015
	U-HS	76.9 (13.9)	76.3 (8.5)	−1.4	−6.9, 4.1	.62
Smoking	R-I	72.3 (24.6)	86.7 (11.9)	16.4	6.9, 26.0	<.001
	R-HS	81.8 (12.7)	84.9 (11.1)	4.3	−0.1, 8.8	.054
	U-I	65.9 (28.1)	77.4 (24.1)	9.3	2.1, 16.4	.011
	U-HS	75.0 (24.4)	79.7 (24.0)	5.1	−4.0, 14.2	.27

CI, confidence interval; CQM, clinical quality measure; R-I, rural independent; R-HS, rural health system; U-I, urban independent; U-HS, urban health system; SD, standard deviation.
↵* R-I includes 20 clinics.
† R-HS includes 34 clinics.
↵‡ U-I includes 55 clinics.
↵‖ U-HS includes 26 clinics.