What’s the “Secret Sauce”? How Implementation Variation Affects the Success of Colorectal Cancer Screening Outreach

Abstract

Background: Mailed fecal immunochemical testing (FIT) programs can improve colorectal cancer (CRC) screening rates, but health systems often vary implementation (i.e., adapt) these programs for their organizations. A health insurance plan implemented a mailed FIT program (named BeneFIT) and allowed participating health systems to adapt the program. This mixed-methods study explored which program adaptations might have achieved higher screening rates.Methods: We used a multi-method approach. First, we conducted a descriptive analysis of CRC screening rates by key health system characteristics and program adaptations. Second, we applied Configurational Comparative Methods (CCMs) to determine potential explanatory factors consistent with higher screening rates. The main outcome measure was CRC screening rates.Results: Seventeen health systems took part in at least one year of BeneFIT. The overall screening completion rate was 20% (4%–28%) in Year 1, and 25% (12%–35%) in Year 2 of the program. Health systems that used two or more adaptations had higher screening rates, and no single adaptation clearly led to higher screening rates. In Year 1, smaller systems (having <2 clinics) with phone reminders (n=2) met the implementation success threshold (≥19% screening rate) while larger systems were successful when offering a patient incentive (n=4), scrubbing mailing lists (n=4), or allowing mailed FIT returns with no other adaptations (n=1). In Year 2, large systems (>2 clinics) were successful with a phone reminder (n=4) or a patient incentive (n=3). Of the 10 systems that implemented BeneFIT in both years, seven improved in Year 2.Conclusions: Health systems can choose between many adaptations and successfully implement a health plan’s mailed FIT program. Screening completion rates are positively associated with the number of adaptations implemented by a health system. Health system size emerged as an important contextual factor, with different solutions for larger than smaller health systems.

Core implementation strategies for improving cirrhosis care in the Veterans Health Administration

“…[21,34] CCMs draw on Boolean algebra and set theory to identify combinations of strategies (configurations) linked to high performance. [18,19,35] Factors analyzed included facility and respondent characteristics and implementation strategies. Following a previously published method, we used the "minimally sufficient condition" function within cna to analyze the complete data set and exhaustively search all 1-, 2-, and 3-condition configurations instantiated in the data set, retaining configurations meeting pre-established consistency (i.e., cases with the outcome and the solution divided by all cases with the solution) and coverage (i.e., cases with the outcome and combination divided by all cases with the outcome) thresholds, and then identify particular combinations of strategies with the strongest connections to the outcome.…”

“…[18][19][20][21] Because CCMs differ from traditional probabilistic regression analytic methods, combining these methods with qualitative data enables convergent validation and mechanistic understanding. [19] This evaluation aimed to (1) identify implementation strategies associated with implementation of EBPs for veterans with cirrhosis, and (2) specify these core strategies for replication in facilities with opportunities to improve cirrhosis care.…”

Use of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to guide iterative adaptations: Applications, lessons learned, and future directions

“…However, there has been little iterative use of these frameworks during the implementation phase or to guide adaptations (13). While Kirk et al have developed the Model for Adaptation Design and Impact (MADI) (14) to comprehensively characterize adaptations and how they impact outcomes and general guidance has been provided in ADAPT-ITT (15), very few empirical studies have evaluated the actual impact of adaptations qualitatively or quantitatively (16)(17)(18). The ADAPT (7) guidance explicitly calls for continuous iterative review of emerging adaptations but did not identify tools or resources for doing Abbreviations: RE-AIM, Reach, E ectiveness, Adoption, Implementation, and Maintenance; PRISM, Practical Robust Implementation and Sustainability Infrastructure.…”

Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot

“…Mailed FIT outreach programs reduce structural barriers to screening completion and may help alleviate observed CRC screening disparities 9,17–19 . However, the ability of clinics and health plans to implement mailed FIT programs and the effectiveness of these programs may be impacted by clinic characteristics (eg, size and geographic region) or program adaptations (eg, reminder calls and incentives) 9,20,21 . Most studies on mailed FIT outreach programs have been conducted in urban settings and large health systems 9 .…”