Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003–2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.

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This article describes a process for integrating health behavior and social science theories with practice-based insights using participatory systems thinking and diagramming methods largely inspired by system dynamics methods. This integration can help close the gap between research and practice in health education and health behavior by offering a systematic approach to bring together stakeholders across multiple domains. In this process we create a diagram using constructs from multiple health behavior theories at all levels of the social ecological framework as variables in causal loop diagrams. The goal of this process is to elucidate the reciprocal relationships between explanatory factors at various levels of the social ecological framework that render so many public health problems intractable. To illustrate, we detail a theory-based, replicable process for creating a qualitative diagram to enrich understanding of caregiver and provider behavior around adherence to pediatric asthma action plans. We describe how such diagramming can serve as the foundation for translating evidence into practice to address real-world challenges. Key insights gained include recognition of the complex, multilevel factors affecting whether, and how effectively, parents/caregivers and medical providers co-create an asthma action plan, and important "feedback" dynamics at play that can support or derail ongoing collaboration. Although this article applies this method to asthma action plan adherence in children, the method and resulting diagrams are applicable and adaptable to other health behaviors requiring continuous, daily action.

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The Quality Payment Program (QPP) is a Medicare Part B reimbursement system designed to incentivize value-based care over volume-based care. The QPP has two tracks for clinicians: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Both QPP tracks require clinicians to adopt and use certified electronic health record technology (CEHRT) for full reimbursement.Not only is CEHRT central to one of the four MIPS scoring categories and a requirement of Advanced APMs, but integrated technology also plays a vital role in a practice's ability to function in a value-based care system. CEHRT can facilitate communication and data sharing between clinicians, which is usually necessary in value-based care models; and CEHRT can ease the burden of reporting, a central component of value-based care models.Some practices, especially those that are small or in rural areas, may lack the resources (financial, staffing, or otherwise) to implement or upgrade health information technology (IT) systems. The QPP provides practices with incentives and penalties to adopt CEHRT; those unable to do so may be uncompetitive under this new reimbursement system. In this issue brief, we discuss the role of CEHRT in the QPP in more detail and offer policy recommendations to help small and rural practices adopt CEHRT, improve health IT capabilities, and participate in value-based care. The QPP and CEHRTUnder the MIPS track of the QPP, Medicare reimbursement is tied to performance on the MIPS score, which has four main components, each carrying a different weight with regard to the total overall score. The four components represent Key Findings• The quality payment program (QPP) is a value-based care reimbursement system for Medicare providers.• For full reimbursement and performance success, the QPP requires practices to fully adopt certified electronic health record technology (CEHRT). CEHRT adoption is a requirement on its own, and related to other QPP requirements such as practice improvement activities and the reporting of quality measures.• Small and rural practices have historically faced barriers in the adoption of CEHRT, and consequently, if practices are unable to participate and succeed in value-based care systems going forward, they may be at risk of monetary penalties.• In this article, the authors make four recommendations for assisting small and rural practices in adopting CEHRT for QPP participation:1. Provide adequate incentive funds for small and rural practices 2. Help clinicians adopt and fully incorporate CEHRT 3. Ensure CEHRT is designed to ease the burden of reporting 4. Encourage virtual reporting and collaborations with Alternative Payment Models (APMs).