Implementation successes and challenges in participating in a pragmatic study to improve colon cancer screening: perspectives of health center leaders

Abstract

Little is known about the challenges faced by community clinics who must address clinical priorities first when participating in pragmatic studies. We report on implementation challenges faced by the eight community health centers that participated in Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), a large comparative effectiveness cluster-randomized trial to evaluate a directmail program to increase the rate of colorectal cancer (CRC) screening. We conducted interviews, at the onset of implementation and 1 year later, with center leaders to identify challenges with implementing and sustaining an electronic medical record (EMR)-driven mailed program to increase CRC screening rates. We used the Consolidated Framework for Implementation Research to thematically analyze the content of meeting discussions and identify anticipated and experienced challenges. Common early concerns were patients' access to colonoscopy, patients' low awareness of CRC screening, time burden on clinic staff to carry out the STOP CRC program, inability to accurately identify eligible patients, and incompatibility of the program's approach with the patient population or organizational culture. Once the program was rolled out, time burden remained a primary concern and new organizational capacity and EMR issues were raised (e.g., EMR staffing resources and turnover in key leadership positions). Cited program successes were improved CRC screening processes and rates, more patients reached, reduced costs, and improved patient awareness, engagement, or satisfaction. These findings may inform any clinic considering mailed fecal testing programs and future pragmatic research efforts in community health centers.

Positive predictive values of fecal immunochemical tests used in the STOP CRC pragmatic trial

“…Given current uncertainty about FIT accuracy, a health system considering implementation of a FIT screening program must weigh the costs and benefits of strategies that lead to greater or lesser use of colonoscopy. We have previously reported on interviews we conducted with 36 leaders in the health centers included in this analysis . Among the factors they considered important in deciding which FIT brand to use, the most common was “quality of results/better test performance,” mentioned by one‐third of respondents.…”

“…We have previously reported on interviews we conducted with 36 leaders in the health centers included in this analysis. 49 Among the factors they considered important in deciding which FIT brand to use, the most common was "quality of results/better test performance," mentioned by one-third of respondents. Clearly, there is demand for comparative test performance data.…”

First-year implementation of mailed FIT colorectal cancer screening programs in two Medicaid/Medicare health insurance plans: qualitative learnings from health plan quality improvement staff and leaders

“…Critical to the expansion of such programs is the need for guidance on program implementation. Published literature describes barriers to and benefits of implementing clinicand health system-based mailed FIT programs [7,11,12], but limited data exist on health insurance plan-based programs. In this study, we explore implementation challenges and successes specific to two health insurance plans (hereafter referred to as health plans) that serve enrollees in U.S. Medicaid and Medicare programs.…”

Diagnostic colonoscopy completion after abnormal fecal immunochemical testing and quality of tests used at 8 Federally Qualified Health Centers in Southern California: Opportunities for improving screening outcomes

“…Compared with health care settings with integrated resources for specialty care, FQHCs face unique challenges in identifying and coordinating care with outside specialty colonoscopy providers that function in separate health care systems. Few prior studies have evaluated rates of colonoscopy follow‐up in FQHC settings, and most either were single‐center or included just a few centers . Second, the effectiveness of FIT‐based programs depends on the brand of FIT selected for implementation.…”

“…Few prior studies have evaluated rates of colonoscopy follow-up in FQHC settings, and most either were single-center or included just a few centers. 9,10 Second, the effectiveness of FIT-based programs depends on the brand of FIT selected for implementation. In its last major evidence review of CRC screening, the US Preventive Services Task Force (USPSTF) concluded that the sensitivity to detect CRC and high-risk adenomas varies widely across stool-based tests that have been approved by the Food and Drug Administration.…”