Factors That Support Sustainability of Health Systems Change to Increase Colorectal Cancer Screening in Primary Care Clinics: A Longitudinal Qualitative Study

Abstract

Background From 2015 to 2020, the Centers for Disease Control and Prevention’s Colorectal Cancer Control Program (CRCCP) supported 30 awardees in partnering with primary care clinics to implement evidence-based interventions (EBIs) and supporting activities (SAs) to increase colorectal cancer (CRC) screening. This study identified factors that facilitated early implementation and sustainability within partner clinics. Methods We conducted longitudinal qualitative case studies of four CRCCP awardees and four of their partner clinics. We used the Consolidated Framework for Implementation Research (CFIR) to frame understanding of factors related to implementation and sustainability. A total of 41 semi-structured interviews were conducted with key staff and stakeholders exploring implementation practices and facilitators to sustainability. Qualitative thematic analysis of interview transcripts identified emerging themes across awardees and clinics. Results Qualitative themes related to six CFIR inner setting constructs—structural characteristics, readiness for implementation, networks and communication, culture, and implementation climate—were identified. Themes related to early implementation included conducting readiness assessments to tailor implementation, providing moderate funding to clinics, identifying clinic champions, and coordinating EBIs and SAs with existing clinic practices. Themes related to sustainability included the importance of ongoing electronic health record (EHR) support, clinic leadership support, team-based care, and EBI and SA integration with clinic policies, workflows, and procedures. Implications Findings help to inform future scale-up of and decision-making within CRC screening programs and other chronic disease prevention programs implementing EBIs and SAs within primary care clinics and also highlight factors that maximize sustainability within these programs.

Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic

“…Specifically, documenting processes and educating clinicians on FIT kit dissemination, patient reminders to complete and return FIT kits, and tracking of dissemination and completion; using automated patient messaging systems to support patient reminders; and delivering patient education can help mitigate disruptions in CRC screening promotion efforts. Second, consistent with previous research, including of the CRCCP [ 18 , 57 , 58 ], clinic champions can help promote CRC screening and maintain clinic staff buy-in to modify existing practices despite competing priorities. Third, support from clinic leadership is essential for continuing CRC screening promotion efforts and exploring innovative solutions to emergent challenges, especially when faced with limited clinic resources and staff capacity [ 42 , 59 ].…”