Pre-implementation adaptation of primary care cancer prevention clinical decision support in a predominantly rural healthcare system

Abstract

Background Cancer is a leading cause of death in the United States. Primary care providers (PCPs) juggle patient cancer prevention and screening along with managing acute and chronic health problems. However, clinical decision support (CDS) may assist PCPs in addressing patients’ cancer prevention and screening needs during short clinic visits. In this paper, we describe pre-implementation study design and cancer screening and prevention CDS changes made to maximize utilization and better fit a healthcare system’s goals and culture. We employed the Consolidated Framework for Implementation Research (CFIR), useful for evaluating the implementation of CDS interventions in primary care settings, in understanding barriers and facilitators that led to those changes. Methods In a three-arm, pragmatic, 36 clinic cluster-randomized control trial, we integrated cancer screening and prevention CDS and shared decision-making tools (SDMT) into an existing electronic medical record-linked cardiovascular risk management CDS system. The integrated CDS is currently being tested within a predominately rural upper Midwestern healthcare system. Prior to CDS implementation, we catalogued pre-implementation changes made from 2016 to 2018 based on: pre-implementation site engagement; key informant interviews with healthcare system rooming staff, providers, and leadership; and pilot testing. We identified influential barriers, facilitators, and changes made in response through qualitative content analysis of meeting minutes and supportive documents. We then coded pre-implementation changes made and associated barriers and facilitators using the CFIR. Results Based on our findings from system-wide pre-implementation engagement, pilot testing, and key informant interviews, we made changes to accommodate the needs of the healthcare system based on barriers and facilitators that fell within the Intervention Characteristics, Inner Setting, and Outer Setting CFIR domains. Changes included replacing the expansion of medical assistant roles in one intervention arm with targeted SDMT, as well as altering cancer prevention CDS and study design elements. Conclusions Pre-implementation changes to CDS may help meet healthcare systems’ evolving needs and optimize the intervention by being responsive to real-world implementation barriers and facilitators. Frameworks like the CFIR are useful tools for identifying areas where pre-implementation barriers and facilitators may result in design changes, both to research studies and CDS systems. Trial registration NCT02986230.

The impact of personalized clinical decision support on primary care patients’ views of cancer prevention and screening: a cross-sectional survey

“…Rates of printing the CDS varied widely between PCPs and clinics during the study, and these rates were low (average print rate during survey timeframe = 53.75%) at the start of the intervention period. This is in part because: (a) over 50% of all patients with adult care visits were not up to date on one or more of the targeted cancer preventive services, slowing down clinic workflow; (b) clinic staff objected to initial SDMT formats, which when printed required many printed pages; and (c) various printing errors were encountered and had to be troubleshot by the study team as they arose [ 26 ]. In response, the SDMT was abbreviated and the initial and abbreviated SDMT formats are included in the Supplemental materials of this report [ 26 ].…”

“…The survey was conducted within a larger RCT on the use of a CDS intervention within 36 primary care clinics randomized across three study arms: (a) usual care (control), (b) cancer prevention CDS alone (CDS), and (c) cancer prevention CDS enhanced with SDMT (CDS + SDMT) [ 15 , 19 , 26 ]. In both intervention arms, a point-of-care and EHR-linked CDS, known as Priorities Wizard [ 27 ], used several sets of web-based algorithms to identify evidence-based cancer prevention care options that address unmet breast, cervical, lung, or colorectal cancer prevention needs.…”

“…In both intervention arms, a point-of-care and EHR-linked CDS, known as Priorities Wizard [ 27 ], used several sets of web-based algorithms to identify evidence-based cancer prevention care options that address unmet breast, cervical, lung, or colorectal cancer prevention needs. PCPs and their patients in the CDS + SDMT intervention arm, in addition to cancer prevention CDS, also had access to short 2–4 page SDMT developed by the study team for patients to more easily understand their personal cancer risk, as well as the risk and benefits of each cancer screening [ 26 ]. The study team modified existing evidence based SDMT based on current literature, expert opinion, and pilot testing [ 26 ].…”

“…PCPs and their patients in the CDS + SDMT intervention arm, in addition to cancer prevention CDS, also had access to short 2–4 page SDMT developed by the study team for patients to more easily understand their personal cancer risk, as well as the risk and benefits of each cancer screening [ 26 ]. The study team modified existing evidence based SDMT based on current literature, expert opinion, and pilot testing [ 26 ]. Rooming staff received an EHR alert for eligible patients instructing them to print the CDS or CDS + SDMT materials (depending on clinic-randomized intervention arm), giving an abbreviated version of the CDS printout (and any SDMT materials) to the patient and placing a more detailed version for the PCP on the exam room door [ 20 ].…”

Implementation Strategies Preferred by Primary Care Clinicians to Facilitate Cancer Prevention and Control Activities

“…(11) Although a wide range of implementation strategies have been identi ed and employed, (12) there is little research on their applicability for different CPC issues or settings. (13) While there has been considerable recent attention to the issue of stakeholder engagement, including clinician involvement in design and adaptation of interventions in primary care,(6, 7) and some on stakeholders in rural settings, (7,14) there has been almost no research on clinicians' perspectives on different implementation strategies.…”