2003b). Quality improvement activities focused on large urban hospitals are more likely to impact a sizable segment of the population and/or to result in improved state averages on quality indicators, and have the added advantage of being geographically more accessible to QIO staff.

In 2002, CMS modified the scope of work for QIOs to include a specific subtask requiring them to improve care for rural beneficiaries or address racial and ethnic disparities in care (CMS, 2003a). However, the evaluation criteria for QIOs still reward improvements in statewide averages on performance indicators. Many QIOs have likely chosen to satisfy the requirements of this subtask by addressing racial or ethnic disparities in urban areas, again because those areas are more geographically accessible to QIO staff and are home to large health care organizations that have a greater impact on statewide performance.

The American Health Quality Association, a membership association representing QIOs, reports that nearly 20 state QIOs are working with critical access hospitals and ambulatory care providers in rural areas (Personal communication, D. G. Schulke, March 18, 2004). Another 17 states, having 20 percent or more of their population residing in rural areas, have no formal rural health project (Personal communication, D. G. Schulke, September 17, 2003).

Although the QIO program as a whole focuses too little attention on rural providers, some QIOs, most notably those in states with large rural populations, are extensively involved in rural quality improvement. For example, Qualis Health in Idaho, in collaboration with the Idaho Hospital Association and the Idaho Department of Health and Welfare, is sponsoring a project for critical access hospitals in Idaho (AHQA, 2004). Stratis Health, the Minnesota QIO, is also working with critical access hospitals on a quality collaborative focused initially on heart failure, smoking cessation, and inpatient influenza and pneumococcal immunizations, with the long-term goal of developing quality initiatives in all clinical areas (Stratis Health, 2004).

One option for addressing this ongoing concern is to decouple the QIOs’ rural health work from their work on disparities in care by creating separate subtasks for each. This approach is recommended by the National Advisory Committee on Rural Health and Human Services in its recent report to the Secretary of Health and Human Services (NACRHHS, 2003). The American Health Quality Association also supports the creation of separate subtasks, but has proposed that QIOs with either very small or very large rural populations be able to opt out of the rural subtask (Personal



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