Building Cancer Prevention and Control Research Capacity in Rural Appalachian Kentucky Primary Care Clinics During COVID-19: Development and Adaptation of a Multilevel Colorectal Cancer Screening Project

Abstract

This study describes the development of a colorectal cancer (CRC) screening multilevel intervention with four primary care clinics in rural Appalachian Kentucky. We also discuss barriers experienced by the clinics during COVID-19 and how clinic limitations and needs informed project modifications. Four primary care clinics were recruited, key informant interviews with clinic providers were conducted, electronic health record (EHR) capacity to collect data related to CRC screening and follow-up was assessed, and a series of meetings were held with clinic champions to discuss implementation of strategies to impact clinic CRC screening rates. Analysis of interviews revealed multilevel barriers to CRC screening. Patient-level barriers included fatalism, competing priorities, and financial and literacy concerns. The main provider- and clinic-level barriers were provider preference for colonoscopy over stool-based testing and EHR tracking concerns. Clinics selected strategies to address barriers, but the onset of COVID-19 necessitated modifications to these strategies. Due to COVID-19, changes in clinic staffing and workflow occurred, including provider furloughs, a state-mandated pause in elective procedures, and an increase in telehealth. Clinics adapted screening strategies to match changing needs, including shifting from paper to digital educational tools and using telehealth to increase annual wellness visits for screening promotion. While significant delays persist for scheduling colonoscopies, clinics were encouraged to promote stool-based tests as a primary screening modality for average-risk patients.

Global Impact of COVID-19 on Colorectal Cancer Screening: Current Insights and Future Directions

“…After the lockdown was lifted, the number of colonoscopy appointments recovered to the number before the pandemic, whereas the noninvasive FIT and stool DNA tests recovered, and exceeded the pre-pandemic numbers [34]. Lastly, the interruption in developing screening programs in the CRC "hotspot" Appalachian Kentucky region elicited a significant backlog, and furthered the barriers that the program already had to face during its development [35].…”

“…This mitigation approach was predicted to provide the additional CRC screening to approximately 588,800 novel patients, and establish about 2899 new CRC diagnoses, out of which 68.9% would be early-stage [19]. Furthermore, the utilization of other noninvasive stoolbased DNA tests was marked effective in identifying high-risk patients, and prioritizing them for diagnostic colonoscopy and CRC treatment [34,35]. Miller et al designed and implemented a novel CRC triage procedure named "COVID-adapted pathway", which successfully ameliorated the adverse effects of the diagnostic colonoscopy backlog [33].…”

“…Furthermore, to ensure that the CRC screening continued, these programs needed to adopt new strategies, such as distributing stool-based CRC screening tests via mail, and shifting from paper to digital educational tools [27,35]. Furthermore, this included telehealth, such as teleconsultation of screen-positive individuals, conducting meetings over the phone, and dedicating call/text centers that would facilitate appointment scheduling [27,32,35]. Human factors, such as proper leadership and the allocation of resources, improved the overall outcome [28].…”

Which innovations can improve timeliness of investigations and address the backlog in endoscopy for patients with potential symptoms of upper and lower Gastrointestinal (GI) cancers?

“…Kruse-Diehr et al (2021) conducted a case study of the development and adaption of a multilevel colorectal cancer (CRC) intervention at four primary care practices in rural Appalachian Kentucky, USA. One of the proposed study objectives was to conduct pilot testing of individually tailored evidence-based interventions that focus on CRC screening and follow-up; however, pilot testing was not performed as some of the study activities were temporarily halted due to the COVID-19 pandemic.…”

A Review of the Impact of the COVID-19 Pandemic on Colorectal Cancer Screening: Implications and Solutions

“…To address the growing backlog of cases seen at every endoscopy unit, multiple physician groups proposed adept triage pathways to identify high risk patients and prioritize alternate screening options like fecal immunochemical testing (FIT) for lower risk groups [30]. Studies of screening triage pathways are summarized in Table 1.…”