title: Organizational and Environmental Correlates to Preventive Quality of Care in US Rural Health Clinics.
abstract: OBJECTIVE
  To identify organizational and environmental correlates to rural health clinics' preventive quality of care in the United States.
  
  
  METHODS
  A retrospective observational cohort study design was applied under Donabedian's Structure-Process-Outcome framework. Three structure measures of care (proportion of nonphysicians, absence of physicians, and provider affiliation) and three measures of process (total clinical visits, prevention use for congestive heart failure and diabetes) were used as explanatory variables. Five environmental correlates were included. The Centers for Medicare and Medicaid Services National Medicare Chronic Care Condition Data Warehouse for 2007 was used to obtain clinical data. Preventive quality of care outcomes were measured through Agency for Healthcare Research and Quality prevention quality indicators. The indicators were risk adjusted for age, sex, race, severity, and comorbidity of patients.
  
  
  METHODS
  Structural equation modeling with maximum likelihood estimation was used.
  
  
  RESULTS
  Provider affiliation (P = .03), absence of physicians (P = .007), and higher proportion of nonphysicians (P = .007) were negatively related to preventive quality of care. Lower cause-specific mortality rate at the county level as compared to the United States average (P = .05) and rural location (P = .001) were positively related to quality of care.
  
  
  CONCLUSIONS
  The results of the study showed the need to attract and retain physicians in rural health clinics. The positive relationship between rural location and quality of care reflects more on the limited access to hospitals in remote areas.
authors.affiliation: Health Plan Research, HealthCore, Wilmington, USA.
authors.forename: Abiy
authors.initials: A
authors.lastname: Agiro
authors.forename: Thomas T H
authors.initials: TT
authors.lastname: Wan
authors.forename: Judith
authors.initials: J
authors.lastname: Ortiz