The study by Soylu et al.1 tested the hypothesis that practices with higher readiness for change would be more likely to implement quality improvement (QI) strategies. The study included 175 small and medium-sized practices in Virginia that, as part of the national EvidenceNOW initiative, received individualized coaching on QI strategies to improve cardiovascular care. The authors measured practice readiness by surveying staff about their commitment to—and confidence in being able to—execute QI strategies. Practice coaches counted the number of QI strategies implemented in three domains: cardiovascular risk reduction, care coordination, and organizational improvement. The study did not find a relationship between readiness and QI strategy implementation in any domain. However, as in the EvidenceNOW initiative overall,2 independent practices were more likely than those owned by hospitals to implement QI strategies.

The lack of relationship between practice readiness and QI strategy implementation is surprising and may have at least two explanations. First, other factors—like adaptive reserve3 or practice’s resources and autonomy to make changes4—might override and obscure the relationship between readiness and QI implementation. Second, the measure of QI activity—a yes/no count for 15 different strategies—emphasized breadth over depth of change. Practices with greater readiness may have selected a few strategies but made large changes within them.

The finding that independent practices were more likely to engage in QI activities is important given the dramatic growth in vertical integration in US healthcare, principally through hospital employment of physicians.5 In theory, vertical integration could facilitate QI activities through more sophisticated electronic health records, easier information exchange across providers, and more resources to support and monitor QI activities. The results from Soylu et al. suggest that vertical integration does not by itself imply greater success in QI strategy implementation and that perhaps the creation of larger delivery organizations may result in more bureaucracy that could stifle efforts to improve quality. These results underscore the need for future research to assess the impact of vertical integration on healthcare quality and outcomes, and to identify approaches to translate the theoretical benefits of integration into quality improvements.