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Medical Care:
doi: 10.1097/MLR.0b013e318286e32e
Original Articles

A Phased Cluster-randomized Trial of Rural Hospitals Testing a Quality Collaborative to Improve Heart Failure Care: Organizational Context Matters

Newhouse, Robin P. PhD*; Dennison Himmelfarb, Cheryl PhD; Morlock, Laura PhD; Frick, Kevin D. PhD; Pronovost, Peter MD, PhD§; Liang, Yulan PhD

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Abstract

Background: Use of evidence-based practices for heart failure (HF) patients has the potential to improve outcomes and reduce variations in care delivery.

Objectives: To evaluate the effect of a rural hospital quality collaborative and organizational context (nurse staffing and practice environment) on 4 HF core measures.

Research Design: Phased cluster-randomized trial with delayed intervention control group. The intervention included a HF toolkit, 2 onsite meetings, and a monthly phone call.

Subjects: Twenty-three rural eastern US hospitals, registered nurses who care for HF patients (N=591).

Measures: Seven quarters of 4 HF core measures, nurse staffing (nursing skill mix, registered nurse hours per patient day, nurse-turnover), and a survey of practice environment.

Results: Using regression models with generalized estimating equation autoregressive methods, no statistically significant changes were found during the intervention period on all 4 core measures for either group. Higher nurse-turnover was related to all 4 core measures: lower compliance with discharge instructions [β=−1.042; 95% confidence interval (CI): −1.777, −0.307], smoking cessation (β=−1.148; 95% CI: −2.180, −0.117), left ventricular ejection fraction (β=−0.893; 95% CI: −1.784, −0.002), and prescribing angiotensin converting enzyme inhibitors on discharge (β=−1.044; 95% CI: −1.820, −0.269). Better practice environment was related to higher left ventricular ejection fraction (β=0.217; 95% CI: 0.054, 0.379).

Conclusions: Significant improvements in 4 core measures were realized in stable environments (less nurse-turnover). Assuring appropriate nurse staffing and stability is essential to increase organizational preparation for quality initiatives and adoption of best practices in HF care in rural hospitals.

© 2013 Lippincott Williams & Wilkins, Inc.

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