A phased cluster-randomized trial of rural hospitals testing a quality collaborative to improve heart failure care: Organizational context matters

Robin P. Newhouse, Cheryl Dennison Himmelfarb, Laura Morlock, Kevin D. Frick, Peter Pronovost, Yulan Liang

Research output: Contribution to journalArticle

11 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)396-403
Number of pages8
JournalMedical care
Issue number5
StatePublished - May 1 2013



  • core measures
  • nursing
  • quality
  • quality collaborative
  • rural hospital

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health

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