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

To compare rural independent and health system primary care practices with urban practices to external practice facilitation support in terms of recruitment, readiness, engagement, retention, and change in quality improvement (QI) capacity and quality metric performance.

The setting consisted of 135 small or medium-sized primary care practices participating in the Healthy Hearts Northwest quality improvement initiative. The practices were stratified by geography, rural or urban, and by ownership (independent [physician-owned] or system-owned [health/hospital system]). The quality improvement capacity assessment (QICA) survey tool was used to measure QI at baseline and after 12 months of practice facilitation. Changes in 3 clinical quality measures (CQMs)-appropriate aspirin use, blood pressure (BP) control, and tobacco use screening and cessation-were measured at baseline in 2015 and follow-up in 2017.

Rural practices were more likely to enroll in the study, with 1 out of 3.5 rural recruited practices enrolled, compared with 1 out of 7 urban practices enrolled. Rural independent practices had the lowest QI capacity at baseline, making the largest gain in establishing a regular QI process involving cross-functional teams. Rural independent practices made the greatest improvement in meeting the BP control CQM, from 55.5% to 66.1% (P ≤ .001) and the smoking cessation metric, from 72.3% to 86.7% (P ≤ .001).

Investing practice facilitation and sustained QI strategies in rural independent practices, where the need is high and resources are low, will yield benefits that outweigh centrally prescribed models.